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DEATH
CERTIFICATE
JOHN SMITH, JR.
Date 22 February 1940
Cert: 7827
Place of Death: County: Letcher City or Town:
rural
Name of Hospital or Institution: Carcassone, Ky.
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County:
Letcher
City or Town: rural Street No.:
Carcassone, Ky.
Full Name: John SMITH, Jr.
If Veteran Name War: (blank)
Social Security No.: none
Sex, Color or Race, Marital Status: Male, White, Single
Husband or Wife of: none
Age of husband or wife if alive: (blank)
Birth date of deceased: 12 February 1939
Age: 01 years, 00 months, 10 days
Birthplace: Knott Co., Ky.
Occupation: None
Industry or business: (blank)
Father Name: John SMITH
Father Birthplace: Knott Co., Ky.
Mother Maiden Name: Aclya Fay RICHARDSON
Mother Birthplace: Knott Co., Ky.
Informant: Sallie COMBS (neighbor), Carcassone, Ky.
Burial Place: Carcassone Cem.
Date: 23 February 1940
Signature of funeral director: family, Carcassone, Ky.
Date received by local registrar: 03 April 1940
Registrar's Signature: E. M. Collins
Date of Death: 22 February 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 10 p.m.
Immediate cause of death: Broncho-Pneumonia
Duration: 05 da.
Due to: Whooping Cough - for 3 wks. (by investigation)
Major findings of operations: none
Accident, suicide, or homicide: (blank)
Date of occurrence: (blank)
Where did injury occur: (blank)
While at work: (blank)
Means of injury: (blank)
Signature & Address: R. D. Collins, M.D., Whitesburg,
Ky.
Date signed: 03 April 1940
Transcribed by Debbie Tamborski, 10 May 2010 |
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