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DEATH
CERTIFICATE
BILL JACOBS
Date 11 June 1940
Cert: 17478
Place of Death: County: Knott City or Town:
Upper Caney
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: Pippapass
Full Name: Bill JACOBS
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Married
Husband or Wife of: Bloomie JACOBS
Age of husband or wife if alive: 78 years
Birth date of deceased: 15 April 1857
Age: 83 years
Birthplace: Knott County
Occupation: Farmer
Industry or business: Farm
Father Name: Henry JACOBS
Father Birthplace: Knott
Mother Maiden Name: Bettie HICKS
Mother Birthplace: Knott
Informant/Address: Frankie JACOBS, Pippapass, Ky.
Burial Place: Pippapass
Date: 12 June 1940
Signature of funeral director/address: (blank)
Date received by local registrar: 02 July 1940
Registrar's Signature: Macie Miller
Date of Death: 11 June
I hereby certify that I attended deceased from 1940 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: Pneumonia
Duration: (blank)
Due to: Age
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: J. W. Duke, M.D., Hindman, Ky.
Date signed: 02 July 1940
Transcribed by Debbie Tamborski, 27 August 2010 |
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