| 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: 203 Markham St. |
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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: 203 Markham St. |
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| 3. |
a. |
Full Name: Mrs. Lela Pearl Bost Hawn |
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| 4. |
Date of death: May 29th, 1954 |
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| 5. |
Sex: Female |
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| 6. |
Color or Race: White |
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| 7. |
a. |
Widowed |
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| 8. |
Birth date: February 18, 1883 |
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| 9. |
Age: 71 years, 3 months, 11 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: Catawba Co. N.C. |
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| 12. |
Citizen of what country: USA |
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| 13. |
Father's Name: Phillip Bost |
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| 14. |
Mother's maiden name: Alice Herman |
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| 15. |
blank |
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| 16. |
Social Security No.: 239-10-3808 |
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| 17. |
Informant's Name and Address: Mrs. Ross Glenn, 203 Markam St., Burlington, N.C. |
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| 18. |
Cause of Death: Possible Heart Attack. interval between onset and death: sudden |
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| 19 |
Blank |
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| 20 |
Autopsy: No |
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| 21. |
blank |
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| 22. |
I hereby certify that I attended the deceased from (not seen alive), and death occured at Early A.M., from the causes and on the date stated above. |
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| 23. |
a. |
Signature: Richard A Fewell, M.D. |
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b. |
Address: Box 1597, Burlington, N.C. |
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c. |
Date signed: June 2, 1957 |
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| 24. |
a. |
Burial, cremation, removal: Burial |
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b. |
Date May 31, 1954 |
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c. |
Cemetery: Pine Hill Cemetery |
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d. |
Location: Burlington, N.C. |
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| . |
a. |
Filed: 6-4-54 |
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b. |
Registrar signature: Mrs. J. Herman |
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| 25. |
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Funeral Director: Rich & Thompson F. Service, Burlington N.C. |
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| Source: photo copy of original document |
