| 1. PLACE of
DEATH
County of: Newberry Township of (or) city of: Newberry 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: Wilson Abney Norris 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: Unknown (spouse: Sarah R. Norris) |
21. DATE OF DEATH
(Mth/Day/Yr): May 26, 1936
| ||
| 6. Date of Birth
(Mth/Day/Yr): April 8,
1870 |
22. I Hereby Certify, That I attended deceased from ---, 19-- to ---, 19--; last saw him alive on --death is said to have occurred on the date stated above, at 11:40 am/pm. | ||
| 7. Age: 66 Years, 1 Months, 20 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 Pectoris (heart attack) | ||
|
OCCUPATION 8. Trade, profession or particular kind of work done, as spinner,
sawyer, bookeeper, 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: Russell County, Mississippi | |||
|
FATHER 13. NAME: John Norris 14. BIRTHPLACE (city or town): --- State or Country: Unavailable |
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: Unavailable 16. BIRTHPLACE (city or town): -- State or Country: Newberry , South Carolina |
24. Was disease or injury in any way
related to occupation of deceased:---. If so, specify--.
Signed: - Address: ---- | ||
| 17. Informant/Address: Sarah R. Norris, Newberry , South Carolina | |||
| 18. BURIAL CREMATION OR REMOVAL: Place: Unavailable Date: Unavailable | |||
| 19. UNDERTAKER/ADDRESS: Unavailable | |||
| 20. FILED: | |||
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