Edwin Washington Project

EWP 4-4 Carrie Hufford Groseclose 01

Item

Title

EWP 4-4 Carrie Hufford Groseclose 01

Description

Certificate of Death

Tag

White Teacher, Certificate of Death

Place

Virginia

Identifier

1020754

Is Version Of

1020754_EWP_Groseclose_Carrie_Hufford_01.jpg

Is Part Of

Petitions

Date Created

1/7/24

Format

Jpeg Image

Number

4c80a06e27b4340336c41a8f5ef70cbdd39f16c41fb518a35eb9e9fac1559328

Source

/Volumes/T7 Shield/EWP/Elements/EWP_Files/Access Files/Upload temp/1020754_EWP_Groseclose_Carrie_Hufford_01.jpg

Publisher

Digitized by Edwin Washington Project

Rights

Loudoun County Public Schools

Language

English

Replaces

/Volumes/T7 Shield/EWP/Elements/EWP_Files/source/Ingest One/4 Faculty Staff and PTAs/4-5_Lists_and_Teacher_Cards/4-5_White_Teacher_Cards/EWP_Groseclose_Carrie_Hufford_01.jpg

extracted text

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Form V. S.



CERTIFICATE OF DEATH

istrati A COMMONWEALTH OF VIRGINIA
g?sgtlrsi::rtaslv‘:)? l \3 3 Registered No. [ S-kb (N DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS

1. PLACE OF DEATH b. MAGISTERIAL DISTRICT 2. USUAL _RESIDENCE (Where deceased lived. If institution: residence before admission.)
JEOUNTY a. STATE b. COUNT 7
< / ;
d/

s ,
d. IS PLACE OF YES -C. R YES []
"INSIDE CITY OR 2

DEATH INSIDE CITY > !
OR TOWN LIMITS? NO [] FEFHF T Z72 g / TOWN LIMITS? NO %
f. LENGTH OF 6. STREET (If ruragl, give mailing address) / f. IS RESIDENCE ON A FARM?

3 STAY ; ADDRE ]
6"7//}/ ( ; 7 %/ / &u/é / /52/ ves [J No [X

I |3 NAME OF a. (First) / b) (Mlddle) . 4. DATE (Month) (Day) (Year)

DECEASED - 7 Ok -
(Type or Print) J//—/ Z / //‘f LI / / / - o DEATH %// ;,2 & /& &

6. COLOR OR RACE 7. MARRIED [7] NEVER MARRIED |:| lGE (I dears‘l IF Ul;DER 1 YEAR | IF UNDER 24 HRS.
ast r.aday) Months Days | Hours | Mins.

A 0, S b
}/9///////@ WIDOWED [ DIVORCED (I |z 5 o/ ' & s
77 12. CITIZEN OF WHAT

USUAL OCCUPATION (Give kind of work 10b. KIND OF BUSINESS OR INDUSTRY!{ 11. BIRTHPLACE”(State or fo.elgn Gountry)
done during most of working life, even if retired) ’ COUNTRY? S
i PQ"'T"“QF’ "c_.r' ho‘v\ il9e U A
| > RamE > " m(A)‘iTDHE%J NAME
| N .
i Dr. Robert Hufford Ellen Richardson =~

i 15 NAME OF HUSBAND OR WIFE OF DECEASED ) T e 17. INFORMANT’S

SIGNATURE 5 S TN
Walter K. Groseclose . Mrs., Elizabeth Dunn

18. CAUSE OF DEATH |[Enter only one cause per line for (a), (b) and (c).] ; INTERVAL BETWEEN
ONSET AND DEATH

PART I. DEATH WAS CAUSED B _
IMMEDIATE CAUSE (a) (et AN 5 ”fi%‘

[{’7 oL ’_/Lclxm\

Conditions; tf any, DUE TO (b)
which gave rise fto
above cause (a),
stating the under-
lying cause last. DUE TO (o)

PART Il. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL D!SEASE CONDITION 19. WAS AUTOPSY
GIVEN IN PART I (a) YEsPE}IiFOl\I;i(I)VIED?

20a. ACCIDENT SUICIDE HOMICIDE| 20b. DESCRIBE HOW INJURY OCCURRED. [Enter nature of injury in Part I or Part II of item 18.]

O O O

20c. TIME OF Hour, Month, Day, Year
INJURY a. m.
p. M.

20d. INJURY OCCURRED | 20e. PLACE OF INJURY (e. g., in or about home, | 20f. CITY, TOWN, OR LOCATION COUNTY
WHILE AT NOT WHILE farm, factory, street, office bldg., etc.)
WORK [ AT WORK [7]

) B = her
21. I attended the deceased from__u_w—’é_L__, to__%and last saw hssealive on / £ Lé‘ -6/

Death occurred at_—____m_fil__m on the date stated above; and to the best of my knowledge, from the causes stated.
22a. SIGNATURE i 22b. ADDRESS) 22c. DATE SIGNED
D = L 7 7 6 Z

N (City. towp or county) ‘ (State)
5

~ MEDICAL CERTIFICATION



/ 23a BUlellébAEI?§MATION ¢ p Y x
\ / 7 7 e : 7% a N 9
,WW%,/ u/z:/ C(/Vl D 96/ T [ ' 7 Al .,,/'/‘ , MGl 210

{ DATE REC’D BY LOCAL REG. REGISTRAR’S SIGNATURE | 24, glUCS‘.“NE:'I'AI}REI W . M/
i \ ! i / /N
3 0 6 t“ { /b /A K, ‘-'/0 Y [' é s i Z -

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Item sets

EWP 04 Faculty Staff and PTAs