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DEATH
CERTIFICATE
CARLOS WILLIAMS
Date 11 July 1942
Cert: 16905
Place of Death: County: Perry City or Town:
Hazard
Hospital or Institution: Hazard Hospital Co.
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County:
Perry
City or Town: Kodak
Full Name: Carlos WILLIAMS
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, Colored,
Married
Husband or Wife of: Omera WILLIAMS
Age of husband or wife if alive: 22 years
Birth date of deceased: 21 January 1907
Age: 34 years
Birthplace: Knott Co.
Occupation: Coal Miner
Industry or business: (blank)
Father Name: West WILLIAMS
Father Birthplace: Knott Co., Ky.
Mother Maiden Name: Maggie WILLIAMS
Mother Birthplace: Knott Co., Ky.
Informant: Omera WILLIAMS, Kodak, Ky.
Burial Place: Breeding Creek
Date: 15 July 1942
Signature of funeral director: Engles, Hazard, Ky.
Date received by local registrar: 11 July 1942
Registrar's Signature: Anna Laura Boulos
Date of Death: 11 July 1942
I hereby certify that I attended deceased from (illegible) to
(blank), that I last saw him alive on (blank), and that death
occurred on the date stated above at 4 a.m.
Immediate cause of death: Peritonitis
Duration: 05 days
Due to: (illegible)
Major findings of operations: (illegible) rt.
Accident, suicide, or homicide: (blank)
Date of occurrence: (blank)
Where did injury occur: (blank)
While at work: (blank)
Means of injury: (blank)
Signature & Address: Chris S. Jackson, M.D., Hazard,
Ky.
Date signed: 20 July 1942
Transcribed by Debbie Tamborski, 30 May 2010 |
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