|
Standard Certificate of Death State of South Carolina Bureau of Vital Statistics State Board of Health 1. PLACE of DEATHCounty of: Newberry File No.- For State Registrar Only | |
| 2. FULL NAME: James Todd Residence: In City---Yrs.---Mth---Days--- | |
|
Personal and Statistical Particulars |
Medical Certificate of Death |
| 3. Sex: Male
4. Color or Race: Colored
5. Single/Married/Widowed/Divorced: Married |
21. DATE OF DEATH
(Mth/Day/Yr): April 8,
1939
|
| 6. Date of Birth (Mth/Day/Yr): April 3, 1903, South Carolina
|
22. I Hereby Certify, That I attended deceased from Nov 15, 1936 to April 8, 1937; last saw him alive on April 7th, 1937, death is said to have occurred on the date stated above, at 3:30 am/pm. |
| 7. Age: Years---Months --, Days -- (If less than 1 day, ---hrs. or ----min.) 61 | The principal cause of death and related causes of importance in order of onset were as follows: ? Hemorrhage |
|
OCCUPATION 8. Trade, profession or particular kind of work done, as spinner, sawyer, bookeeper, etc: -----. Farmer 9. Industry or business in which work was done, as silk mill, saw mill, bank, etc: -----. Own Farm 10. Date deceased last worked at this occupation (Mth & Yr): ----. Nov. 1936 11. Total time (years) spent in this occupation: -----. |
Was this death due to pregnancy or to childbirth?
If so, sate which ----.
Contributory causes of importance not related to principal cause: Cho. Myocarditia & Cho. Nephritis. Name of operation ----. Date of ---. What test confirmed diagnosis? ---. Was there an autopsy?-- |
| 12. BIRTHPLACE (city or town): Newberry State or Country: South Carolina | |
|
FATHER 13. NAME: Thomas Kitt 14. BIRTHPLACE (city or town): Newberry State or Country: South Carolina
|
23. If death was due to external causes
(violence) fill in also the following: Accident, suicide, or
homicide: ---. Date of injury --, 19--.
Where did injury occur (city/town/state; industry, home, public place)? --- Manner of injury:--- Nature of injury:--- |
|
MOTHER 15. MAIDEN NAME: Fannie Todd 16. BIRTHPLACE (city or town): Newberry State or Country: South Carolina |
24. Was disease or injury in any way related to
occupation of deceased:---. If so, specify--.
Signed: J E Grant Address: Newberrry, SC |
| 17. Informant/Address: Carrie Todd, South Greenwood, South Carolina | |
| 18. BURIAL CREMATION OR REMOVAL: Place: Wertz Cemetery Date: April 11, 1939 | |
| 19. UNDERTAKER/ADDRESS: Williams & Pratt Newberry, South Carolina | |
| 20. FILED: April 12, 1939 | |
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