1. |
Name of deceased: Roy H. Leftin |
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2. |
Date of Death: 6-24-72 |
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3. |
Sex: Male |
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4. |
Color or Race: White |
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5. |
State of Birth: N.C. |
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6. |
Date of Birth: 7-29-99 |
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7. |
Age: 72 years |
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8. |
Place of death |
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a. |
County: Haywood |
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b. |
City or town: Waynesville |
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c. |
Name of Hospital or Institution: Haywood Co. Hospital |
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d. |
Inside city limits: yes |
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9 |
Usual Residence |
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a. |
State: N.C. |
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b. |
County: Haywood |
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c. |
City or town: Canton |
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d. |
Street Address: 51 Ballew Street |
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e. |
Inside city limits: yes |
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10. |
Married |
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11. |
Surviving spouse: Mae Marrow |
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12. |
Citizen of what country: USA |
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13. |
Social Security No.: blank |
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14. |
a. |
Usual occupation: Southern Railway |
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b |
Kind of business or industry: blank |
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15. |
Father's Name: Alonzo Loftin |
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16. |
Mother's maiden name: Cornelia Lowrance |
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17 |
Informant's Name and address: Mae Loftin - 51 Ballew Street, Canton, N.C. |
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18. |
a. |
Immediate cause of death: Shock heart failure, duration: 1 hour |
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b. |
due to Acute myocardial infarction, duration: 6 hours |
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c. |
due to Coronary Therosclerosis, duration: year |
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19. |
a. |
blank |
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b. |
Autopsy: yes |
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c. |
Was findings considered in determining cause of death? yes |
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20. |
blank |
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21. |
I attended the deceased from 1968 to 6-24, 1972 and last saw him alive on 6-24-1972. Death occurred at 11:15pm on the date stated above, and in my opinion, from the causes stated. |
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22. |
blank |
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23. |
a |
Signature of Certifier: R. Fedite, M.D. |
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b. |
Date signed: 6-27-72 |
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c. |
Address: R. Fedite Waynesville, N.C. |
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24. |
a. |
Burial, cremation, other: Burial |
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b. |
Date: 6-26-72 |
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c. |
Name of Cemetery: Bethelem United Meth Church |
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d. |
Location: Statesville, N.C. |
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25. |
Funeral Home: Ralph M. Crawford Funeral Home, Inc. N. Main Street, Canton, N.C. |
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26. |
Signature of Funeral director: Dorothy B. Crawford. License No. 741 |
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27. |
Date rec'd by local reg.: 29/June/72 |
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28. |
Signature of Registrar: Haywood Co. Health Dept. |
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29. |
Signature of Embalmer: Ralph M. Crawford, License No. 372 |