1 |
Place of Death |
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a. |
County: Granville |
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b. |
Township: Dutchville |
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c. |
City or Town: Butner, N.C.; Is place |
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d. |
Full Name of hospital or institution: State Hospital |
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e. |
Length of stay in hospital or institution: 1yr, 1mo, 9days |
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2. |
Usual Residence |
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a. |
State: North Carolina |
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b. |
County: Cabarrus |
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c. |
City or Town: Concord |
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d. |
street adress: 155 N. Crowell Street |
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e. |
Is place of residence in corporate limits? Yes |
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3. |
Name of deceased: Grady Wardlow White |
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a. |
If veteran name war: blank |
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b. |
Social Security No. Blank |
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4. |
Sex: male |
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5. |
Color or Race: White |
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6. |
married |
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7. |
Date of Birth: Sept. 18, 1887 |
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8. |
Age: 61 yrs, 3 mos, 1 dys |
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9. |
Birthplace: Cabarrus County, N.C. |
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10 |
Usual Occupation: none |
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11. |
Kind of business or industry: inmate |
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12. |
Father's Name: Frank Edward White |
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13. |
Birthplace: Cabarrus County |
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14. |
Mother's Maiden Name: Mary Delila Bost |
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15. |
Birthplace: Cabarrus County |
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16. |
a. |
Informant's signature: Mrs. Gladys M. Gray |
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b. |
Address: State Hospital, Butner, N.C. |
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17. |
a |
Burial, cremation, removal: Removal |
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b. |
Date: 12-19-48 |
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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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18. |
a |
Funeral director: Weddington - Mitchell |
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b. |
Address: Concord, N.C. |
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19. |
a. |
filed: 12-29-1948 |
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b. |
Registrar's Signature: Bal Norwood |
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20. |
Date of death: Dec. 19, 1948 at 12:40pm |
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21. |
I certify that that death occurred on the date above stated; that I attended deceased from Nov. 10, 1947 to Dec. 19, 1948 and that I last saw him alive on Dec. 19, 1948.
Immediate cause of death: Chronic Myocerditis - duration: 2 weeks |
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22. |
blank |
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23. |
a |
Signature: James G. Randoch M.D. |
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b. |
Address: State Hospital, Butner, N.C. |
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c. |
Date signed: 12/20/48 |