First things and last : the story of birth and death certificates.
- United States. National Office of Vital Statistics
- Date:
- [1960]
Licence: Public Domain Mark
Credit: First things and last : the story of birth and death certificates. Source: Wellcome Collection.
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![The Death Certificate The death certificate also has many important uses. (See below.) No burial permit can be issued un- til the certificate is properly made out and signed. In clearing up an estate the legal proof of the indi- vidual’s death rests upon the certif- icate filed at the time of his death. Without it, a life insurance claim will not be paid promptly (or some- times not paid at all), Nor can a survivor’s social security benefits be collected without proof of death. Compensation for death on account of an industrial ac- 1 Fi proved. : CERTIFICATE OF DEATH Fore approved oe RSTEE. BIRTH No. . STATE. OF STATE FILE No. 1. PLACE OF DEATH 2, USUAL RESIDENCE ( Where deceased lived. If institution: Residence before admission) a. COUNTY a, STATE 6. COUNTY =P ae) PENVuckK’ : b. CITY, TOWN, OR LOCATION ¢. LENGTH OF STAY IN 16] €. CITY, TOWN, OR LOCATION . Memphis one gay Ma jeld (If not in hospital, give street address) d. STREET ADDRESS Firat Middle Last 4, DATE ‘Month Day —SYear DECEASED (Type or print) DEATH Ap ril 9, 1959 osepn Pa “| Do 6 COLOR OR RACE 7. marriep [X) NEVER MARRIED L)| © OATE OF BIRTH 9. AGE (In yeafs | iF UNDER | YEAR |iF UNDER 24 HRS. last birthday) Min. ite wioowen (] pivorceoL} March 89 6 bbe © ibe 10a. USUAL OCCUPATION (Give kind of work done | 105. KIND OF BUSINESS OR INDUSTRY | 11, BIRTHPLACE (State or foreign country) 12. CITIZEN OF WHAT COUNTRY? during most of working life, even if retired) w Py seeds uck D 3 fholesale Groce ogland United States S = 13. FATHER'S NAME 14. MOTHER'S MAIDEN NAME al nn = z Pa oseph Doe Mas ane Smith 2115. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY NO.| 17. INFORMANT Add j 3] Chettnes or unbnown) | lf rege war of dae of er) ies oad Mayfield, eo ees World War I 607-05-9823 |Mrs. JeP. Doe, 189 N. 5th St., Kentucky ~ a 18. CAUSE OF DEATH [Enter only one cause per line for (a), (5), and (c).) URE ae s + PART |. DEATH WAS CAUSED BY: ONSET AND H ral IMMEDIATE cause (a) Gangrene of Colon 10 we @ Conditions, ifany, ) pue to («o) Complete Obstruction of Colon eeks er which gave rise to * z = stp cpa a stating the under- * 5 < Iving” cause Tat, | ove To ()_ Carcinoma of Sigmoid Colon _ ---=--== : Fs ro PART iI, OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART I(a) . es, a Araneae E]e eieg 7 8 8 S ves) xo s 5 * [20c. ACCIDENT SUICIDE HOMICIDE | 206. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Part I or Part II of item 18.) “15 O O Oo | 2c. TIME OF Hour Month, Day, Year Pn] INJURY a. m. 715 p.m. ro) Fi 20d. INJURY OCCURRED Qe. PLACE OF INJURY (¢. 9., in or about home, | 20/. CITY, TOWN, OR LOCATION COUNTY STATE = WHILE AT o NOT WHILE Oo farm, factory, street, office bldg., etc.) : g WORK AT WORK & 21. J attended the deceased from SADE LL. Oana to cAprid. 9 and last saw Fy al aliveon April 9S aee 8 Death occurred at pO Ls Se gees ee m on the date stated above; and to the best of my knowledge, from the causes stated. 22a, SIGNATURE De title 22b. ADDRESS Ze. DATE SIGNED es ee Vamtg Hospital ra A 2, fo BE J. Re Jones, M. D Memon ennesseeé 4/9/59 = ] 23a. BURIAL (CREMATION: ~ | 235. DATE 23, NAME OF CEMETERY OR CREMATORY 23d. LOCATION (City, town. or county) (State) Ff REMOVAL (Specify) f A & 9/1960 Pine Hill Cemetery Mayfield, Kentucky B | 24. FUNERAL DIRECTOR ADDRESS 25. DATE RECD. BY LOCAL REG. 26, REGISTRAR’S SIGNATURE d ?|_ABC Funeral Home ‘ayfield, Kentucky | April 11, 1960 dim Gans aN](https://iiif.wellcomecollection.org/image/b32177471_0006.jp2/full/800%2C/0/default.jpg)
