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DEATH
CERTIFICATE
JOHN SMITH
Date 16 March 1930
Cert: 06310
Place of Death: Voting Pct.: Asylum, Eastern State Hopt.,
Lexington, Fayette Co., Ky.
Full Name: John SMITH
Residence: Breathitt Co., Ky.
Length of Residence: (blank)
Sex, Color or Race, Marital Status: Male, White, Married
Husband or Wife of: Mrs. John SMITH
Date of Birth: 1857
Age: 78 years
Occupation: Farmer
Birthplace: Knott Co., Ky.
Father Name: Unknown
Birthplace Father: "
Mother Maiden Name: "
Birthplace Mother: "
Informant/Address: Alex SMITH, Haddix, Ky.
Burial Cremation Removal Place: E. S. Hospt.
Date: 21 March 1935
Undertaker/Address: E. S. Hospt., Lex., Ky.
Filed: 22 March 1935
Registrar: D. A. Furlong
Death of Date: (blank)
I hereby certify, That I attended deceased from 13 March 1935 to
16 March 1935, that I last saw him alive on 16 March 1935, death is said
to have occurred on the date stated above, at 6:20 p.m.
Cause of Death: Broncho Pneumonia
Date of onset: 11 March 1935
Contributory causes: Senile Psychosis
Date of onset: 1930
Name of operation: (blank)
What tests confirmed diagnosis: (illegible)
Was there an autopsy: no
Accident, suicide, homicide: (blank)
Date of Injury: (blank)
Where did injury occur: (blank)
Specify whether injury occurred industry, home, public place:
Manner of injury: (blank)
Nature of injury: (blank)
Related to occupation: no
Signed/Address: A. B. Carter, E. S. Hospt., Lexington,
Ky.
Transcribed by Debbie Tamborski, 17 April 2010 |
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