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DEATH
CERTIFICATE
JASON SMITH
Date 04 July 1941
Cert: 18410
Place of Death: County: Perry City or Town:
Rural
Street No. or Location: Hardburley
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County: Perry
City or Town: Rural If rural
precinct: #19
Full Name: Jason SMITH
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: 13 August 1913
Age: 26 years, 11 months, 21 days
Birthplace: Knott Co., Ky.
Occupation: Farmer
Industry or business: (blank)
Father Name: Jasper SMITH
Father Birthplace: Knott Co., Ky.
Mother Maiden Name: Matilda RICHIE
Mother Birthplace: Knott Co., Ky.
Informant: Jasper SMITH, Hardburley, Ky.
Burial Place: Dwarf, Ky.
Date: 05 July 1941
Signature of funeral director: Engle Und. & Hdwe., Hazard, Ky.
Date received by local registrar: 27 July 1941
Registrar's Signature: Kathryn S. Johnson
Date of Death: 04 July 1941
I hereby certify that I attended deceased from February 1941 to
04 July 1941, that I last saw him alive on 03 July 1941, and that death
occurred on the date stated above at (blank)
Immediate cause of death: Pulmonary Tuberculosis
Duration: 04 months
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: H. W. Gingles, M.D., Hardburley,
Ky.
Date signed: 12 July 1941
Transcribed by Debbie Tamborski, 14 May 2010 |
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