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DEATH
CERTIFICATE
BERNARD DWAINE MELLAND
Date: 23 November 1940
Cert: 29244
Place of Death: County: Knott City or Town:
Hindman
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: Hindman
Full Name: Bernard Dwaine MELLAND
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Single
Husband or Wife of: (blank)
Age of husband or wife if alive: (blank)
Birth date of deceased: 06 March 1932
Age: 00 years, 08 months, 17 days
Birthplace: Allegan, Michigan
Occupation: (blank)
Industry or business: (blank)
Father Name: Harold W. MELLAND
Father Birthplace: Chicago, Ill.
Mother Maiden Name: Mildred BUSFIELD
Mother Birthplace: Allegan, Michigan
Informant/Address: Harold W. MELLAND, Ivis, Ky.
Burial Place: Emmalena, Ky.
Date: 25 November 1940
Signature of funeral director/address: family
Date received by local registrar: 30 December 1940
Registrar's Signature: Macie Miller
Date of Death: 23 November 1940
I hereby certify that I attended deceased from 23 November
1940 to
23 November 1940, that I last saw him alive on 23 November
1940, and that death occurred on the date stated above at 3
p.m.
Immediate cause of death: Lobar Pneumonia
Duration: (blank)
Due to: (blank)
Major findings of operations: (blank)
Of autopsy: (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: M. F. Kelley, M.D., Hindman,
Ky.
Date signed: 30 December 1940
Transcribed by Debbie Tamborski, 28 August 2010 |
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