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DEATH
CERTIFICATE
JOHN JACOBS
Date: 09 December 1952
Cert: 27069
Place of Death: County: Wolfe City/Town: Belknap,
Ky.(rural)
Length of stay (in this place): Life
Name of Hospital or Institution: (blank)
Usual Residence of Deceased: State: Ky. County:
Wolfe
City or Town: Belknap (rural) Street Address: (blank)
Full Name: John JACOBS
Date of Death: 09 December 1952
Sex, Color or Race, Marital Status: Male, White, Married
Date of Birth: 03 September 1886
Age: 66 years
Usual Occupation: Farmer
Kind of Industry or business: Farming
Birthplace: Knot Co., Ky.
Father's Name: George JACOBS
Mother's Maiden Name: Lydia CENTERS
Was deceased ever in armed forces: Yes, World War I
Social Security No.: none
Informant: Rush Margaret JACOBS
Disease or condition directly leading to death: Suside [sic]
Interval between onset and death: (blank)
Due to: Self inflicted gunshot in forehead
Other significant conditions: (blank)
Date of Operation: (blank)
Major findings of operation: (blank)
Autopsy: (blank)
Accident, suicide, or homicide: (blank)
Place of injury: (blank)
City or Town, County, State: (blank)
Time of Injury: (blank)
Injury occurred at work: (blank)
How did injury occur: (blank)
I hereby certify that I attended deceased from (blank) to
(blank), that I last saw the deceased alive on (blank), and
that death occurred at 4:30 p.m., from the causes and on the
date stated above.
Date signed: 01 January 1953
Address: Campton, Ky.
Signature: (illegible)
Burial, Cremation or Removal: Burial
Date: 11 December 1952
Name of Cemetery or Crematory: Family
Location: Belknap, Ky.
Date received by local registrar: 01 January 1953
Registrar's Signature: Irene Spencer
Funeral director & address: H. D. Potter, West
Liberty, Ky.
Transcribed by Debbie Tamborski, 11 August 2010 |
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