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DEATH
CERTIFICATE
SAM TERRY
Date 06 December 1940
Cert: 29248
Place of Death: County: Knott City or Town:
Rural
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: Life
Usual Residence of Deceased: State: Ky. County:
Knott
City or Town: Rural
Full Name: Sam TERRY
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Widowed
Husband or Wife of: Susy TERRY
Age of husband or wife if alive: Deceased
Birth date of deceased: 01 December 1875
Age: 65 years,00 months, 06 days
Birthplace: Knott Co.
Occupation: Farmer
Industry or business: (blank)
Father Name: Bill TERRY
Father Birthplace: Knott Co., Ky.
Mother Maiden Name: Polly MAGGARD
Mother Birthplace: Knott Co.
Informant/Address: Bert TERRY, Mousie, Ky.
Burial Place: Hindman, Ky.
Date: 08 December 1940
Signature of funeral director/address: W. J. Ryan, Martin, Ky.
Date received by local registrar: 12 December 1940
Registrar's Signature: Macie Miller
Date of Death: 06 December 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 7 p.m.
Immediate cause of death: Apoplexy
Duration: (blank)
Due to: Hypertension
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: W. L. Stumbo, M.D., Lackey, Ky.
Date signed: (blank)
Transcribed by Debbie Tamborski, 27 August 2010 |
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