| 1. |
Place of Death |
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a. |
County: Alamance |
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b. |
Township: blank |
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c. |
Length of stay: blank |
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d. |
City or town: Burlington; is place of death within city limits: yes |
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e. |
Street, hospital or institution: Alamance County Hospital |
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| 2. |
Home (usual residence) of deceased |
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a. |
State: N.C. |
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b. |
County: Alamance |
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c. |
City or town: Burlington; Is place of residence in corporate limits? yes |
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d. |
Street: 1332 Collins Drive |
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| 3. |
a. |
Full Name: Mrs. Addie Basinger Bost |
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| 4. |
Date of death: March 17th, 1958 |
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| 5. |
Sex: Female |
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| 6. |
Color or Race: White |
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| 7. |
a. |
married |
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| 8. |
Birth date: February 4, 1885 |
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| 9. |
Age: 73 years, 1 months, 13 days |
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| 10. |
a. |
Usual Occupation: Housewife |
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b |
Kind of business or industry: housekeeping |
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| 11. |
Birthplace: Rowan Co. N.C. |
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| 12. |
Citizen of what country: USA |
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| 13. |
Father's Name: Calvin Basinger |
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| 14. |
Mother's maiden name: Miranda Crowell |
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Name of Husband or Wife: Mr. Earl L. Bost |
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| 15. |
blank |
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| 16. |
Social Security No.: blank |
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| 17. |
Informant's Name and Address: Mr. Earl L. Bost, 1332 Collins Drive, Burlington, N.C. |
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| 18. |
Cause of Death: |
| I |
a. |
Immediate cause: Cardiac insufficiencey; duration: 2 weeks |
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b. |
due to: arteriosclerotic heart disease; duration: many years |
| II |
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Other conditions: bleeding from diverticulosis of colon. |
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| 19 |
Autopsy: Yes |
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| 20 |
Blank |
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| 21. |
I attended the deceased from 4/24/1954 to 3/16/1958 and last saw her alive on 3/17/1958. Death occurred at 1:10am on the date stated above; and to the best of my knowledge from the causes stated. |
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| 22. |
a. |
Signature: G. Walker Blin, Jr, M.D. |
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b. |
Address: Burlington, N.C. |
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c. |
Date signed: 3/21/58 |
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| 23. |
a. |
Burial, cremation, removal: Burial |
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b. |
Date March 19, 1958 |
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c. |
Cemetery: Pine Hill Cemetery |
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d. |
Location: Burlington, N.C. |
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| 24. |
a. |
Filed: 3/26/58 |
| 25. |
b. |
Registrar signature: Mrs. J. Herman |
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| 26. |
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Funeral Director: Rich & Thompson F. Service, Burlington N.C. |
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| Source: photo copy of original document |
