|
Standard Certificate of Death State of South Carolina Bureau of Vital Statistics State Board of Health 1. PLACE of DEATHCounty of: Greenwood Township of (or) city of: -- Home address: South Greenwood 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: Minnie Lee Butler Residence: In City---Yrs.---Mth---Days--- | |
|
Personal and Statistical Particulars |
Medical Certificate of Death |
| 3. Sex: Female 4. Color or
Race: White
5. Single/Married/Widowed/Divorced: Single |
21. DATE OF DEATH (Mth/Day/Yr): February 3, 1925
|
| 6. Date of Birth (Mth/Day/Yr): April 3, 1903, South Carolina
|
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---Months --, 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: Post typhoidal (toxemia); typhoid fever |
|
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: Ned Butler 14. BIRTHPLACE (city or town):---- 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: Ann Hastings 16. BIRTHPLACE (city or town):--- 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: Ned Butler, South Greenwood, South Carolina | |
| 18. BURIAL CREMATION OR REMOVAL: Place: Greenwood Date: February 24, 1925 | |
| 19. UNDERTAKER/ADDRESS: H. B. Ellis, Greenwood Co, South Carolina | |
| 20. FILED: | |
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