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DEATH
CERTIFICATE
SAMPSON ANDERSON SMITH
Date 04 August 1941
Cert: 20603
Place of Death: County: Madison City or Town: Richmond, Ky.
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County: Madison Co.
City or Town: Richmond, Ky.
Full Name: Sampson ANDERSON SMITH
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Single
Husband or Wife of: Single
Age of husband or wife if alive: (blank)
Birth date of deceased: 11 November 1917
Age: 23 years, 08 months, 23 days
Birthplace: Knott Co., Ky.
Occupation: Garrage Employe [sic]
Industry or business: (blank)
Father Name: J. D. SMITH
Father Birthplace: Perry Co., Ky.
Mother Maiden Name: R. Milda COMBS
Mother Birthplace: Knott Co., Ky.
Informant: Mrs. J. D. SMITH, Richmond, Ky.
Burial Place: Hazard, Ky.
Date: 06 August 1941
Signature of funeral director: (illegible), Richmond, Ky.
Date received by local registrar: 05 August 1941
Registrar's Signature: L. I. Burnett
Date of Death: 04 August 1941
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 6:30 a.m.
Immediate cause of death: (blank)
Duration: (blank)
Due to: Broken neck and crushed skull
Major findings of operations: (blank)
Accident, suicide, or homicide: Accident
Date of occurrence: 04 August 1941
Where did injury occur: Lancaster Pike
While at work: (blank)
Means of injury: Auto accident turned over
Signature & Address: Luther Jenkins,
Coroner, M.C., Richmond, Ky.
Date signed: 05 August 1941
Transcribed by Debbie Tamborski, 14 May 2010 |
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