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DEATH
CERTIFICATE
ADILINE FUGATE
Date 27 December 1940
Cert: 05791
Place of Death: County: Perry City or Town:
Rural
Name of Hospital or Institution: Blue Diamond, Ky.
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County:
Perry
City or Town: Rural Street No.:
#11
Full Name: Adiline FUGATE
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Female, White,
Married
Husband or Wife of: Dave FUGATE
Age of husband or wife if alive:
Birth date of deceased: 14 January 1874
Age: 66 years, 11 months, 13 days
Birthplace: Knott Co., Ky.
Occupation: House wf.
Industry or business: (blank)
Father Name: Pat TIGNOR
Father Birthplace: Knott Co.
Mother Maiden Name: Margarett NEWLAND
Mother Birthplace: Knott Co.
Informant: Truman FUGATE, Blue Diamond, Ky.
Burial Place: Burial - Tribby, Ky.
Date: 29 December 1940
Signature of funeral director: Engle Und. & Hdwe., Hazard, Ky.
Date received by local registrar: 15 February 1941
Registrar's Signature: Kathryn S. Johnson
Date of Death: 27 December 1940
I hereby certify that I attended deceased from 24 December
1940 to
27 December 1940, that I last saw her alive on 27 December
1940, and that death occurred on the date stated above at 11
a.m.
Immediate cause of death: (blank)
Due to: Uremia Poisoning
Duration: 1/2 year
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: (illegible), Blue Diamond, Ky.
Date signed: 11 February 1941
Transcribed by Debbie Tamborski, 08 May 2010 |
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