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DEATH
CERTIFICATE
Mrs. ROBERT
GAYHART (SITHA)
Date 05 June 1940
Cert: 15676
Place of Death: County: Perry City or Town: Rural (Lost Creek)
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County:
Perry
City or Town: Rural Street No.:
#20
Full Name: Mrs. Robert GAYHART (Sitha)
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Female, White,
Divorced
Husband or Wife of: Robert GAYHART
Age of husband or wife if alive: 73 years
Birth date of deceased: 03 March 1874
Age: 66 years
Birthplace: Knott County
Occupation: Housewife
Industry or business: (blank)
Father Name: Sam SMITH
Father Birthplace: Ky.
Mother Maiden Name: Diana COMBS
Mother Birthplace: Ky., Perry Co.
Informant: Hardburley
Burial Place: Lost Creek
Date: 07 June 1940
Signature of funeral director: (blank)
Date received by local registrar: 11 June 1940
Registrar's Signature: Kathryn Johnson
Date of Death: 05 June 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 (blank)
Immediate cause of death: according to information received
from relative this woman died of coronary occlusion
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: D. D. (illegible), Hazard
Date signed: 17 June 1940
Transcribed by Debbie Tamborski, 09 May 2010 |
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