| 1. PLACE of
DEATH
County of: Newberry Township of (or) city of:-- Home address:--
|
Standard Certificate of Death State of South Carolina Bureau of Vital Statistics State Board of Health Registration District No.-- (No-----St.;------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: Eula Lane Wilson Residence: In City Newberry Yrs.---Mth---Days--- | |||
|
Personal and Statistical Particulars |
Medical Certificate of Death | ||
| 3. Sex: F 4. Color or Race: White
5. Single/Married/Widowed/Divorced: Widowed, husband: J.W. Wilson |
21. DATE OF DEATH
(Mth/Day/Yr): May 11, 1940
| ||
| 6. Date of Birth
(Mth/Day/Yr): February 21, 1872
|
22. I Hereby Certify, That I
attended deceased from ---------, 19-- to ---, 19--; last saw h--
alive on ---, 19--, death is said to have occurred on the date stated
above, at ---am/pm.
| ||
| 7. Age: Years 68 Months 2 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: Chronic pyelonephritis. | ||
|
OCCUPATION 8. Trade, profession or particular kind of work done, as spinner, sawyer, bookeeper, etc: ---. 9. Industry or business in which work was done, as silk mill, saw mill, bank, etc:-----. 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: South Carolina | |||
|
FATHER 13. NAME: J.C. Lane 14. BIRTHPLACE (city or town): Newberry State or Country: South Carolina
|
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: Elizabeth Buzhardt 16. BIRTHPLACE (city or town): Newberry State or Country: South Carolina |
24. Was disease or injury in any way
related to occupation of deceased:---. If so, specify--.
Signed:---- Address:---- | ||
| 17. Informant/Address: Mrs. Odell Wilson | |||
| 18. BURIAL CREMATION OR REMOVAL: Place Rosemont Cemetery, Date May 12, 1940 | |||
| 19. UNDERTAKER/ADDRESS: James Lavell Funeral Home, Newberry, SC | |||
| 20. FILED: | |||
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