|
DEATH
CERTIFICATE
SIMON MOORE
Date 24 July 1940
Cert: 16565
Place of Death: County: Floyd Co. City or Town:
Martin, Ky.
Name of Hospital or Institution: Rural
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County:
Floyd
City or Town: Alphoretta, Ky.
Street No.: Rural
Full Name: Simon MOORE
If Veteran Name War: (blank)
Social Security No.: 403-10-1259
Sex, Color or Race, Marital Status: Male, White,
Divorced
Husband or Wife of: Gracie ROBERTS
Age of husband or wife if alive: 28 about
Birth date of deceased: 06 November 1914
Age: 25 years, 09 months, 18 days
Birthplace: Knott Co.
Occupation: Miner
Industry or business: Stevens Elkhorn
Father Name: Lenard MOORE
Father Birthplace: Knott Co.
Mother Maiden Name: Marry SPARTMAN
Mother Birthplace: Knott Co.
Informant: Johnie MOORE, Martin, Ky.
Burial Place: Nippa, Ky.
Date: 25 July 1940
Signature of funeral director: G. D. Ryan, Martin, Ky.
Date received by local registrar: 31 July 1940
Registrar's Signature: Mrs. Ben Norris
Date of Death: 24 July 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 6:50 a.m.
Immediate cause of death: Double Lobar Pneumonia
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: B. S. Walden, M.D., Martin, Ky.
Date signed: (blank)
Transcribed by Debbie Tamborski, 10 May 2010 |
|