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DEATH
CERTIFICATE
JASPER LUCUS
Date: 01 February 1940
Cert: 12869
Place of Death: County: Knott City or Town:
Amburgey
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: Amburgey
Full Name: Jasper LUCUS
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Married
Husband or Wife of: Roda LUCUS
Age of husband or wife if alive: 51 years
Birth date of deceased: 18 August 1884
Age: 56 years
Birthplace: Letcher Co.
Occupation: Farmer
Industry or business: (blank)
Father Name: Arch LUCUS
Father Birthplace: Letcher Co.
Mother Maiden Name: Mary Ann SARGENT
Mother Birthplace: Letcher
Informant/Address: E. A. (illegible)
Burial Place: Amburgey
Date: 03 February 1940
Signature of funeral director/address: (blank)
Date received by local registrar: 25 May 1940
Registrar's Signature: Macie Miller
Date of Death: 01 February 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: accidental absorption of
poisonous gas
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: J. W. Duke, Hindman, Ky.
Date signed: 26 May 1940
Transcribed by Debbie Tamborski, 27 August 2010 |
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