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DEATH
CERTIFICATE
CALLIE COUCH
Date 01 January 1944
Cert: 02815
Place of Death: County: Perry City or
Town: Hazard
Name of Hospital or Institution: Hazard Hospital Co.
Length of stay in hospital or community:
Usual Residence of Deceased: State: Ky.
County: Knott
City or Town: Anco
Full Name: Callie COUCH
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Female, White, Single
Husband or Wife of: (blank)
Age of husband or wife if alive: (blank)
Birth date of deceased: 16 December
Age: 16 years
Birthplace: Perry Co.
Occupation: (blank)
Industry or business: (blank)
Father Name: Delouis COUCH
Father Birthplace: Ky.
Mother Maiden Name: Elizabeth BARGER
Mother Birthplace: Ky.
Informant: Henry (illegible), Anco, Ky.
Burial Place: Saul
Date: 02 January 1944
Signature of funeral director: Engles, Hazard
Date received by local registrar: 01 January 1944
Registrar's Signature: Anna L. Boulos
Date of Death: 01 January 1944
I hereby certify that I attended deceased from 31 December
1943 to
01 January 1944, that I
last saw him alive on 01 January 1944, and that death occurred on the date
stated above at 5:30 a.m.
Immediate cause of death: Pulmonary tuberculosis
(illegible)
Due to: (blank)
Major findings of operations: (blank)
Accident, suicide, or homicide: (blank)
Date of occurrence: (blank)
Where did injury occur: (blank)
While at work: (blank)
Means of injury: (blank)
Signature: Chris S. Jackson, M.D., Hazard, Ky.
Date signed: 01 January 1944
Transcribed by Debbie Tamborski, 07 February 2010 |
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