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DEATH
CERTIFICATE
ADAM STACY SR.
Date: 28 July 1951
Cert: 15365
Place of Death: County: Breathitt City or Town:
Jackson, Ky.
Length of stay (in this place): (blank)
Name of Hospital or Institution: (blank)
Usual Residence of Deceased: State: Kentucky County: Breathitt
City or Town: Jackson Street Address: (blank)
Full Name: Adam STACY Sr.
Date of Death: 28 July 1951
Sex, Color or Race, Marital Status: Male, White, Married
Date of Birth: 16 June 1872
Age: 79 years
Usual Occupation: Retired Hotel Mgr.
Kind of Industry or business: (blank)
Birthplace: Knott Co., Ky.
Father's Name: El STACY
Mother's Maiden Name: Seatta BRADLEY
Was deceased ever in armed forces: (blank)
Social Security No.: (blank)
Informant: Dr. Adam STACY Jr.
Disease or condition directly leading to death: Uremia
Interval between onset and death: (blank)
Due to: Senile cardio - renal degeneration
Other significant conditions: Diabetes mellitus
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 April 1951 to
25 July 1951, that I last saw the deceased alive on 25 July
1951, and
that death occurred at (blank), from the causes and on the
date stated above.
Date signed: 21 August 1951
Address: Jackson, Ky.
Signature: F. C. Lewis, M.D.
Burial, Cremation or Removal: Burial
Date: 30 July 1951
Name of Cemetery or Crematory: Marcum Heights
Location: Breathitt Co., Ky.
Date received by local registrar: 01 August 1951
Registrar's Signature: Gladys H. Deaton
Funeral director & address: Ray & Blake, Jackson,
Ky.
Transcribed by Debbie Tamborski, 31 July 2010 |
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