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DEATH
CERTIFICATE
JOHNNY COUCH
Date 19 March 1940
Cert: 17488
Place of Death: County: Knott City or Town:
Rural Sass.
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County:
Knott
City or Town: Sassafras
Full Name: Johnny COUCH
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Single
Husband or Wife of: (blank)
Age of husband or wife if alive: (blank)
Birth date of deceased: 14 February 1940
Age: 01 months, 05 days
Birthplace: Ky.
Occupation: (blank)
Industry or business: (blank)
Father Name: Bradley COUCH
Father Birthplace: Ky.
Mother Maiden Name: Cloye SANDLIN
Mother Birthplace: Ky.
Informant/Address: Bradley COUCH, Sassafras
Burial Place: Chavies
Date: 21 March 1940
Signature of funeral director/address: William
S. Norris, Hazard, Ky.
Date received by local registrar: 09 July 1940
Registrar's Signature: Macie Miller
Date of Death: 19 March 1940
I hereby certify that I attended deceased from (blank) to
(blank), that I last saw him alive on (blank), and that death
occurred on the date stated above at 6 p.m.
Immediate cause of death: Premature birth
Duration: (blank)
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 & Address: Guy C. Pinckley, M.D.
Date signed: (blank)
Transcribed by Debbie Tamborski, 17 August 2010 |
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