| 1. PLACE of
DEATH
County of: Newberry Township of (or) city of: Newberry Home address: Newberry |
Standard Certificate of Death State of South Carolina Bureau of Vital Statistics State Board of Health Registration District No. 34A (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 20871 Registered No.(for use of Local Registrar) 71 | |
| 2. FULL NAME: Mrs. Octavia Young Residence: In City---Yrs.---Mth---Days--- | |||
|
Personal and Statistical Particulars |
Medical Certificate of Death | ||
| 3.
Sex: Female 4. Color or Race: Colored 5. Single/Married/Widowed/Divorced: Widowed |
21. DATE OF DEATH (Mth/Day/Yr): Nov. 3, 1927 | ||
| 6. Date of Birth
(Mth/Day/Yr):
March 1843 |
22. I Hereby Certify, That I attended deceased from Oct 28, 1927 to Nov 3, 1927, that I last saw her alive on Nov 3, 1927, and that death occurred on the date stated above, at 8:45 Am/pm. The CAUSE OF DEATH* was as follows: Cerebral Hemorrhage | ||
| 7. Age: Years 84 Months 6 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: Maternity Nurse 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): Newberry Co. State or Country: South Carolina | |||
|
FATHER 13. NAME: Alec. Calomese 14. BIRTHPLACE (city or town): Don’t
known
|
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: Nellie Don’t Know 16. BIRTHPLACE (city or town):----------State or Country:----------- |
24. Was disease or injury in any way
related to occupation of deceased:---. If so, specify--.
Signed:---- Address:---- | ||
| 17. Informant/Address: Mr. S.M. Young, Newberry | |||
| 18. BURIAL CREMATION
OR REMOVAL: Place Werts | |||
| 19. UNDERTAKER/ADDRESS: Patterson & Pratt,
Newberry | |||
| 20. FILED: Dec 12, 1927 S.S. Cunningham | |||
| 1. PLACE of
DEATH
County of: Newberry Township of (or) city of: Newberry Home address: Newberry |
Standard Certificate of Death State of South Carolina Bureau of Vital Statistics State Board of Health Registration District No. 34A (No 417 - Caldwell St.; 4th Ward) If death occurred in a Hospital or institution give its NAME instead of street and number
|
File No.- For State Registrar Only 2920 Registered No.(for use of Local Registrar) 10 | |
| 2. FULL NAME: Anderson J. Moon Residence: In City---Yrs.---Mth---Days--- | |||
|
Personal and Statistical Particulars |
Medical Certificate of Death | ||
| 3.
Sex: Male
4. Color or Race: Colored 5. Single/Married/Widowed/Divorced: Married, 5a. If married, widowed, or divorced HUSBAND of: Sallie L. Moon |
21. DATE OF DEATH (Mth/Day/Yr): Feb. 7, 1940 | ||
| 6. Date of Birth
(Mth/Day/Yr):
March 1843 |
22. I Hereby Certify,
That I attended deceased
from Jan. 1st, 1940 to Feb. 7th, 1940 I last saw him alive
on Feb. 7th, 1940, death is said to have occurred on the date stated
above, at 8:30 am/pm. The principal cause
of death and related causes of importance in order of onset were as
follows: c Metastatic Granoths to Liver
| ||
| 7. Age: Years 75 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: Granite Cutter 9. Industry or business in which work was done, as silk mill, saw mill, bank, etc: Monumental Works. 10. Date deceased last worked at this occupation (Mth & Yr): Nov. 1939. 11. Total time (years) spent in this occupation : 50. |
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): Newberry Co. State or Country: South Carolina | |||
|
FATHER 13. NAME: Not Known 14. BIRTHPLACE (city or
town): Not known
|
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: Bettie Moon 16. BIRTHPLACE (city or town): Edgefield Co, SC State or Country:----------- |
24. Was disease or injury in any way
related to occupation of deceased:---. If so, specify--.
Signed:---- Address:---- | ||
| 17. Informant/Address: Sallie Moon, Newberry | |||
| 18. BURIAL CREMATION
OR REMOVAL: Place Wertz | |||
| 19. UNDERTAKER/ADDRESS: Williams & Pratt, Newberry | |||
| 20. FILED: March 1st, 1940 John . Baxter | |||
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