| 1. |
Place of Death |
| |
a. |
County: Alamance |
| |
b. |
Township: Burlington |
| |
c. |
Length of stay: blank |
| |
d. |
City or town: Burlington, N.C.; Is place of death within city limits: yes |
| |
e. |
Street, hospital or institution: Alamance Memorial Hospital |
| |
|
|
| 2. |
Home (usual residence) of deceased |
| |
a. |
State: N.C. |
| |
b. |
County: Alamance |
| |
c. |
City or town: Burlington; Is place of residence in corporate limits? yes |
| |
d. |
Street: 1605 Wood Ave. |
| |
|
|
| 3. |
a. |
Full Name: Hazel Smith Hawn |
| |
|
| 4. |
Date of death: 10-26-63 |
| |
| 5. |
Sex: Female |
| |
|
|
| 6. |
Color or Race: White |
| |
|
|
| 7. |
a. |
Married |
| |
|
|
| 8. |
Birth date: 4-5-1918 |
| |
|
|
| 9. |
Age: 45 |
| |
|
|
| 10. |
a. |
Usual Occupation: Textile Worker |
| |
b |
Kind of business or industry: Tower Hos. |
| |
|
| 11. |
Birthplace: Catawba Co. N.C. |
| |
|
|
| 12. |
Citizen of what country: USA |
| |
|
|
| 13. |
Father's Name: D.M. Smith |
| |
|
|
| 14. |
Mother's maiden name: Bessie Isley |
| |
Name of Husband or Wife: Phillip Neal Hawn, Sr. |
| |
|
|
| 15. |
blank |
| |
|
|
| 16. |
Social Security No.: 239-03-3115 |
| |
|
|
| 17. |
Informant's Name and Address: Phillip Neal Hawn, Sr., 1605 Wood Ave. Burlington, N.C. |
| |
|
|
| 18. |
a) Cause of Death: Subarachnois Hemorrhage. interval between onset and death: 24 hours |
| |
b) Dut to Hypertensive Vascular Disease |
| |
|
|
| 19 |
Blank |
| |
|
|
| 20 |
Autopsy: blank |
| |
|
|
| 21. |
I attended the deceased from 10-25-1963 to 10-26-1963 and last saw her alive on 10-26-1963. Death occurred at 3:45a.m. on the date stated above; and to the best of my knowledge from the causes stated. |
| |
|
|
| 22. |
a) signature: Alex F. Goley, M.D.
b) Address: 1509 Vaughn Rd, Bur.
c) Date signed: 10-29-63 |
| |
|
|
| 23. |
a. |
Burial, cremation, removal: Burial |
| |
b. |
Date: 10-27-63 |
| |
c. |
Cemetery: Alamance Memorial Park |
| |
d. |
Location: Alamance, N.C. |
| |
|
|
| 24. |
a. |
Date Rec'd by local Reg.: 10-29-63 |
| |
|
|
| 25. |
Registrar's Signature: W. L. Norville, M.D. |
| |
|
|
| 26 |
Funeral Director: Burke Funeral Home, Inc. Burlington, N.C. |
| |
|
| Source: photo copy of original document |
