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DEATH
CERTIFICATE
DORA SLONE JACOBS
Date 23 October 1940
Cert: 26570
Place of Death: County: Knott City or Town:
Pippapass
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Kentucky County:
Knott
City or Town: Pippapass
Full Name: Dora SLONE JACOBS
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Female, White, Married
Husband or Wife of: Ben JACOBS
Age of husband or wife if alive: don't know
Birth date of deceased: don't know
Age: 68 years
Birthplace: Knott Co.
Occupation: House wife
Industry or business: (blank)
Father Name: Jeff SLONE
Father Birthplace: Knott
Mother Maiden Name: Sally SLONE
Mother Birthplace: Knott Co.
Informant/Address: Frankie S. JACOBS, Pippapass
Burial Place: Pippapass
Date: 25 October 1940
Signature of funeral director/address: Family, Pippapass
Date received by local registrar: 19 November 1940
Registrar's Signature: Macie Miller
Date of Death: 23 October 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: Pulmonary Tuberculosis
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: Frankie S. Jacobs, Pippapass
Date signed: 11 November 1940
Transcribed by Debbie Tamborski, 27 August 2010 |
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