Death Certificate for Glennie Leopard
| Registration Dist. No.:
Registrar's No.: Birth No.: |
Standard Certificate of Death Division of Vital Statistics - State Board of Health State of South Carolina |
State File No.: 3676 | |||||||||
| 1. PLACE OF DEATH: (a) County: Laurens |
2. USUAL RESIDENCE: (where
deceased lived. If institution; residence before admission)
(a) State: South Carolina (b) County: | ||||||||||
| (b) City or town (if outside corporate limits, write Rural and give township): | (c) City or town (if outside corporate limits, write Rural and give township): | ||||||||||
| (d) Full name of hospital or institution
(if not in hospital or institution, give street address or location): |
(d) Street Address (if rural, give location): | ||||||||||
| 3. NAME OF DECEASED: a. (First)
Glennie |
b. (Middle) c. (Last)
Leopard |
4. Date of Death (Month, Day, Year): March 8, 1921, (Clinton?) township, Laurens Co, SC | |||||||||
| 5. Sex: Female
|
6. Color or race: White
|
7. Married, never married, widowed,
divorced:
Married |
8. Date of birth:
July (21), 1899, Newberry Co, SC
|
9. Age (in years last
birthday):
| |||||||
| 10a. Usual occupation (give kind of work done during most of working life, even if retired): Barber | 10b. Kind of business or industry: | 11. Birthplace: | 12. Citizen of what country? | ||||||||
| 13a. Father's name: Arthur Milton/Melton, Darlington Co, South Carolina | 13b. Mother's maiden name: Emma Boozer, Newberry Co, South Carolina | 14. Husband or wife's name: | |||||||||
| 15. Was deceased ever in US armed forces (yes, no, unknown. If yes, give war or dates of service): | 16. Social Security No. | 17. Informant: Arthur Milton/Melton, Clinton, SC | |||||||||
|
Medical Certification |
|||||||||||
| 18. Cause of Death: Pulmonary Edema
I. Disease or condition directly leading to death (a) due to (b) due to (c) II Other significant conditions (conditions contributing to the death but not related to the disease or condition causing death) |
Interval Between Onset and Death: | ||||||||||
| 19a Date of operation: | 19b: Major findings of operation: | 20. Autopsy: YES NO | |||||||||
| 21a. Accident, Suicide, Homicide: | 21b. Place of injury (home, farm, factory, street, office bldg., etc.): | 21c. City, Town, or Township; County; State | |||||||||
| 21d. Time of injury (Month, Day, Year, Hour): | 21e. Injury occurred (while @ work, not @ work): | 21f. How did injury occur?: | |||||||||
| 22. I hereby certify that I attended the deceased from ----, 19--, to ---, that I last saw the deceased alive on --, and that death occurred at ---, from the causes and on the date stated above. | |||||||||||
| 23a. Signature, Degree or Title: | 23b. Address: | 23c. Date signed: | |||||||||
| 24a. Burial, cremation, removal:
|
24b. Date: |
24c. Name of cemetery or crematory: (Harris Church?) |
24d. Location (city, town or county, state): | ||||||||
| Date rec'd by local registrar: | Registrar's signature: | 25. Funeral director, address: Dibble Co, Clinton, South Carolina | |||||||||
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