1 |
Place of Death |
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a. |
County: Granville |
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b. |
Township: Dutchville |
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c. |
Length of stay: 0-6-20 |
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d. |
City or Town: Butner, N.C.; Is place of death within city limits: blank |
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e. |
Full Name of hospital or institution: State Hospital at Butner, N.C. |
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2. |
Usual Residence |
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a. |
State: North Carolina |
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b. |
County: Warren |
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c. |
City or Town: no information; Is place of residence in city limits? blank |
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d. |
street adress: no information |
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3. |
Name of deceased: Lizzie Bost Daniel |
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4. |
Date of death: Sept. 9, 1950 |
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5. |
Sex: Female |
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6. |
Color or Race: White |
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7. |
widowed |
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8. |
Date of Birth: Dec. 14, 1871 |
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9. |
Age: 78 yrs, 4 mos, 25 dys |
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10. |
a. |
Usual Occupation: inmate |
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b. |
Kind of business or industry: none |
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11. |
Birthplace: Cabarrus County, N.C. |
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12. |
Citizen of what country: blank |
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13. |
Father's Name: Martin Bost |
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14. |
Mother's Maiden Name: Miss Crowell |
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15. |
Was deceased ever in US Armed forces: blank |
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16. |
Social Security No.: blank |
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17. |
Informant's name and address: Mrs. Gladys M. Gray, Butner, N.C. |
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18. |
Cause of death: Generalized Carcinoma of the breast. Interval between onset and death: 1 year. |
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19. |
Date of operation: blank |
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20. Autopsy: blank |
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21. |
Blank |
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22. |
I hereby certify that I attended the deceased form Oct. 19, 1949 to Sept. 9, 1950, that I las saw the deceased alive on Sept. 9, 1950 and that death occurred at 1:15pm from the causes and on the date stated above. |
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23. |
a |
Signature: James G. (unable to decipher) M.B. |
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b. |
Address: State Hospital, Butner, N.C. |
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c. |
Date signed: 9-12-50 |
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24 |
a |
Burial, cremation, removal: Removal |
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b. |
Date: 9-9-50 |
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c. |
Name of cemetery or crematory: No information |
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d. |
Location: Newton, no information |
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25 |
Date rec'd by local reg.: 9-16-50 |
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26 |
Registrar's Signature: Jeo. E. Watson |
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27. |
Funeral director & address: Blaylock Funeral Home, Littleton, N.C. |