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DEATH
CERTIFICATE
POLLY NOBLE
Date: 04 October 1951
Cert: 23949
Place of Death: County: Breathitt City or Town:
Clayhole, Ky., Rural
Length of stay (in this place): (blank)
Name of Hospital or Institution: (blank)
Usual Residence of Deceased: State: Ky. County:
Breathitt
City or Town: Clayhole - Rural Street Address: (blank)
Full Name: Polly NOBLE
Date of Death: 04 October 1951
Sex, Color or Race, Marital Status: Female, White, Married
Date of Birth: 16 March 1867
Age: 84 years
Usual Occupation: Housewife
Kind of Industry or business: (blank)
Birthplace: Knott Co., Ky.
Father's Name: Ben GRIGSBY
Mother's Maiden Name: Martha FUGATE
Was deceased ever in armed forces: (blank)
Social Security No.: (blank)
Informant: Mrs. Chester ROBERTS
Disease/condition directly leading to death:
Arteriosclerotic heart disease with congestive heart failure &
secondary pneumonia
Interval between onset and death: (blank)
Due to: (blank)
Other significant conditions: Senility
Date of Operation: (blank)
Major findings of operation: (blank)
Autopsy: no
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
04 October 1951, that I last saw the deceased alive on (blank), and
that death occurred at (blank), from the causes and on the
date stated above.
Date signed: 19 December 1951
Address: Jackson, Ky.
Signature: F. C. Lewis, M.D.
Burial, Cremation or Removal: Burial
Date: 07 November 1951
Name of Cemetery or Crematory: Family
Location: Breathitt, Ky.
Date received by local registrar: 21 December 1951
Registrar's Signature: Gladys H. Deaton
Funeral director & address: Johnson Funeral Home,
Hazard, Ky. by L. Riley Townsend
Transcribed by Debbie Tamborski, 30 July 2010 |
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