/Volumes/T7 Shield/EWP/Elements/EWP_Files/source/Ingest One/2 Petitions Plans School Board and Districts/2-5A_Colored_Petitions/2-5A_Leesburg/Petition_Leesburg_U_To_1935/EWP_Russ_Death_certificate.jpg
extracted text
1 PLACE OENDEATH : CERTIFICATE OF DEATH
COMMONWEALTH OF VIRGINA
COUNTY OF : DEPARTMENT OF HEALTH 1()6 O ;
MAGISTERIAL
DISTRICT OF . BUREAU OF VITAL STATISTICS
OR é ~
INC. TOWN OF .REGISTRATION DisTRICT No. ¢ EGISTERED NoO
s (TO BE INSERTED BY REGISTRAR) (FOR USE OF LOCAL REGISTRAR)
CITY OF (N O Y = ST.
(If death occurred in a hospital or other institution, give its NAME instead of street and number)
7-10-36—40M.
Length of residence in city or town where death occurred
2 FULL NAME e
& /) ‘:: L " g " i ) ‘,‘r" A
(A) RESIDENCE. —‘ ’ — A Syl e WARD
(Usual pla:ce of aboe) (If nonresident give city or town and State)
PERSONAL AND STATISTICAL PARTICULARS J MEDICAL CERTIFICATE OF DEATH
4. COLOR OR RACE |5. SINGLE, MARRIED, WIDOWED, 21. DATE OF DEATH
OR DIVORCED (write the wopd) (month, day, and year)
-
5A. IF MARRIED, WIDOWED, OR DIVORCED . AT AL ... /-’J . 2 ........
_ G P repenstan Raddd g e e
6. DATE OF BIRTH (month, day, and year)
7. AGE Years Months Days IF LESS THAN
EVERY ITEM OF INFORM-
PHYSICIANS SHoULD STATE THE CAUSE OF
EXACT STATEMENT OF OCCUPATION 1s VERY IMPORTANT
THIS IS A PERMANENT RECORD.
RADE, PROFESSION, OR PARTICULAR
KIND OF WORK DONE, AS SPINNER,
SAWYER, BOOKKEEPER, ETC
INDUSTRY OR BUSINESS IN WHICH
WORK WAS DONE, AS SILK HILL, SAW
MILL, BANK, ETC.
. DATE DECEASED LAST WORKED AT 11I. TOTAL TIME (YEARS) -
THIS OCCUPATION (month and SPENT IN THIS
CUPATION.
OCCUPATION
N
]
=
O
g
<
L
o
L
=
<
=
172]
51
m
a
=
=
o
X
0
|51
o
=L
MARGIN RESERVED FOR BINDING
12. BIRTHPLACE (city or town) .
(State or country)
NAME OF OPERATION
. WHAT TEST CONFIRMED DIAGNQSIS?
] PL city or town n 2 N7 fomsssstssienssersen D) T S P SIS N i Mo ans e
I4 BIRTH A(CSEt i % t )) 23. IF DEATH WAS DUE TO EXTERNAL CAUSES (VIOLENCE) FILL IN ALSO THE
i 0 ey FOLLOWING: DATE OF
ACCIDENT, SUICIDE, OR HOMICIDE?..c reeeeeeee--.- INJURY-comemeeceananenenncannanacns i te
WHERE DID INJURY OCCUR? - :
16. BIRTHPLACE (city or town) (Specify city or town, county, and State)
(State or country) e SPECIFY WKETHER INJURY OCCURRED IN INDUSTRY, IN HOME, OR IN PUBLIC
MOTHER | FATHER
17. INFORMANT ., K R AN .
(ADDRESS) ) MANNER OF INJURY
NATURE OF INJURY
24. WAS DISEASE OR INJURY IN ANY WAY RELATED TO OCCUPATION OF