| 1. PLACE of
DEATH
County of: Newberry Township of (or) city of: Newberry Home address: Wright St.
|
Standard Certificate of Death State of South Carolina Bureau of Vital Statistics State Board of Health Registration District No. 34-A (No Wright St.; 5th Ward) If death occurred in a Hospital or institution give its NAME instead of street and number
|
File No.- For State Registrar Only
Registered No.(for use of Local Registrar) | |
| 2. FULL NAME: Daniel Jacob DeHardt Residence: In City---Yrs.---Mth---Days--- | |||
|
Personal and Statistical Particulars |
Medical Certificate of Death | ||
| 3. Sex: Male
4. Color or Race: White
5. Single/Married/Widowed/Divorced: Married 5a. If married, widowed, or divored Husband or Wife of: Non Stated |
21. DATE OF DEATH
(Mth/Day/Yr): Apr. 15, 1938
| ||
| 6. Date of Birth
(Mth/Day/Yr): Jan.
2, 1856 |
22. I Hereby Certify, That I attended deceased from April 15, 1938 to April 15, 1938; last saw him alive on April 14, 1938, death is said to have occurred on the date stated above, at 2 am/pm. | ||
| 7. Age: 82 Years, 3 Months, 13 Days (If less than 1 day, ---hrs. or ----min.) | The principal cause of death and related
causes of importance in order of onset were as follows: Angina Pectors Date of onset: 90, 94a | ||
|
OCCUPATION 8. Trade, profession or particular kind of work done, as spinner,
sawyer, bookeeper, etc: Textile Worker 10. Date deceased last worked at this occupation (Mth & Yr): - 11. Total time (years) spent in this occupation: - |
Was this death due to pregnancy or to
childbirth? If so, sate which ----.
Contributory causes of importance not related to principal cause: ----. Name of operation ----. Date of ---. What test confirmed diagnosis? ---. Was there an autopsy?-- | ||
| 12. BIRTHPLACE (city or town): State or Country: Lexington County, South Carolina | |||
|
FATHER 13. NAME: Allen DeHardt 14. BIRTHPLACE (city or town): --- State or Country: Lexington Co., SC |
23. If death was due to external causes
(violence) fill in also the following: Accident, suicide, or
homicide: ---. Date of injury --, 19--. Where did injury occur (city/town/state; industry, home, public place)? --- Manner of injury:--- Nature of injury:--- | ||
|
MOTHER 15. MAIDEN NAME: Catherine Sease 16. BIRTHPLACE (city or town): -- State or Country: Lexington , SC |
24. Was disease or injury in any way
related to occupation of deceased: No. If
so, specify--.
Signed: J. H. McCullough Address: Newberry, SC | ||
| 17. Informant/Address: Mrs. D. J. DeHardt, Newberry, SC | |||
| 18. BURIAL CREMATION OR REMOVAL: Place: Newberry Date: June 16, 1938 | |||
| 19. UNDERTAKER/ADDRESS: Leavell Funeral Home, Newberry, SC | |||
| 20. FILED: April 4th, 1938, Jno. H. Baxter | |||
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