1. |
Name of deceased: Earl Latinous Bost |
2. |
Date of Death: 10-4-1971 |
3. |
Sex: Male |
4. |
Color or Race: White |
5. |
State of Birth: North Carolina |
6. |
Date of Birth: 5-23-1887 |
7. |
Age: 84 years |
8 |
Place of death |
|
a) County: Orange |
|
b) City or Town: Chapel Hill |
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c) Name of Hospital or Instiution: N.C. Memorial Hospital |
|
d) Inside city Limits: Ye |
9. |
Usual Residence |
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a) State: North Carolina |
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b) County: Alamance |
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c) City or Town: Burlington |
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d) Street Address: 1406 Collins Drive |
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e) Inside City Limits: Yes |
10. |
Marital Status: Widowed |
11. |
Surving Spouse: Addie Basinger Bost/d |
12. |
Citizen of What Country: U.S.A. |
13. |
Social Security Number: 237-84-1519 |
14. |
a) Usual Occupation: Hosiery Mill Owner |
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b) Kind of business or industry: Textile Industry |
15. |
Father's Name: Solomon David Bost/d |
16. |
Mother's Maiden Name: Mattie Carter Bost/d |
17. |
Informant's Name & Address: Hospital Records - N.C. Memorial Hospital, Chapel Hill, N.C. |
18. |
Death Caused By |
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a) Immediate Cause: Cardiopulmonary Arrest |
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b) Due to: Re____ tachycardia |
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c) Due to: ASHD |
19. |
a) Other significant conditions: blank |
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b) Autopsy: No |
|
c) blank |
20. |
a) Accident, Suicide, Homicide or Undetermined: blank |
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b) How injury occurred: blank |
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c) Time of injury: 10-4-71 8:30a.m. |
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d) Injury at work: blank |
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e) Place of injury: blank |
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f) City: blank |
21. |
Certification - Physician: I attended the deceased from 10-3-1971 to 10-4-1971 and last saw him alive on 10-4-1971. Death occurred at 8:30a.m. on the date stated above and in my opinion from the causes stated. |
22. |
Blank |
23. |
a) Signature of certifier: W. N. Bay M.D. |
|
b) Date signed: 10-4-71 |
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c) Address: NCMH Chapel Hill, N.C. |
24. |
a) Burial, Cremation, other: Burial |
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b) Date: 10-6-71 |
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c) Name of cemetery or crematory: Pine Hill Cemetery |
|
d) Location: Burlington, N.C. |
25. |
a) Funeral Home: Rich & Thompson Fun. Home; Burlington, N.C. |
26. |
Signature of Funeral Director: S. Lloyd Carter; License No. 1913 |
27. |
Date rec'd by local reg: 10-13-71 |
28. |
Signature of Registrar: David Garvine M.D. |
29. |
Signature of Embalmer: S. Lloyd Carter; License No. 1060 |
| Source: photo copy of original document |
