| 1. PLACE of
DEATH
County of:-Newberry
|
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 12537
Registered No.(for use of Local Registrar) | |
| 2. FULL NAME: Thomas Wadlington Keitt 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 |
21. DATE OF DEATH (Mth/Day/Yr): Aug. 31, 1922 | ||
| 6. Date of Birth
(Mth/Day/Yr): Jan 11, 1859
|
22. I Hereby Certify, That I attended deceased from June 1, 1922 to Aug 31, 1922; last saw him alive on Aug 31, 1922, death is said to have occurred on the date stated above, at 4 am/pm. | ||
| 7. Age: Years 63 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: ? | ||
|
OCCUPATION 8. Trade, profession or particular kind of work done, as spinner, sawyer, bookeeper, etc: farmer. 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): Richland Co. State or Country: SC | |||
|
FATHER 13. NAME: Col. Ellis W. Keitt 14. BIRTHPLACE (city or town): Orangeburg 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: Caroline James Wadlington 16. BIRTHPLACE (city or town): Newberry Co. South Carolina |
24. Was disease or injury in any way
related to occupation of deceased:---. If so, specify--.
Signed:---- Address:---- | ||
| 17. Informant/Address: T. E. Keitt, Newberry, SC | |||
| 18. BURIAL CREMATION OR REMOVAL: Place Rosemont Cemetery, Date Sept 2, 1922 | |||
| 19. UNDERTAKER/ADDRESS: R. Leavell, Newberry, SC | |||
| 20. FILED: | |||
Back to Newberry County South Carolina Genealogy Trails