COMMONWEALTH OF VIRGINIA — CERTIFICATE OF DEATH
DEPARTMENT OF HEALTH — BUREAU OF VITAL STATISTICS
COPY A
FOR BUREAU OF
VITAL STATISTICS
REGISTRATION CERTIFICATE
AREA/yMBé
. FULL NAME
OF DECEASED
(first)
Alice G,
. DATE OF [day)
" Now. 30, 1962
6. NAME OF HOSPITAL OR
INSTITUTION OF DEATH
DECEDENT
(mo) (year) 4.
(if none, so state)
None
(if rural, so state)
Aldie
. STATE (OR FOREIGN COUNTRY) OF
DECEASED'S RESIDENCE X g ..
Virginig
Aldie
8. CITY OR TOWN
OF DEATH
USUAL
RESIDENCE
OF DECEDENT
. CITY OR TOWN
OF RESIDENCE
14. NAME OF FATHER
OF DECEASED
~=”' : 3
to/Mds Owen Taylor
ITIZEN OF
WHAT COUNTRY
U.S.A,
‘6 17.
PERSONAL
DATA OF
DECEDENT
NUMBER / /
: /
. IF VETERAN, name war, or if
. peacetime only, so state
STATE FILE
NUMBER
(middle)
Hutehison
AGE OF L
91 - &
DECEASED
. COUNTY OF
DEATH
female
X
5. COLOR
OR RACE
White
. STREET ADDRESS OR RT. NO.
OF PLACE OF DEATH
inside city or town limits?
yes no
1 Bd
. COUNTY OF DECEASED'S
RESIDENCE
Loudoun
. STREET ADDRESS OR RT. NO.
OF RESIDENCE
el
inside city or town limits?
yes no
O X
. MAIDEN NAME OF
MOTHER OF DECEASED
Anng Smith
IF MARRIED CR WIDOWED,
NAME OF SPOUSE
Milton Bengamin Hutchison
BIRTHPLACE 22. DATE OF BIRTH (mo) (day)
OF DECEASED OF DECEASED
Virginia Jan, 30,1871
NEVER MARRIED 18
MARRIED D D
winowed [57] DIVORCED |:|
(year)
21. (state or country)
23. USUAL OR LAST
OCCUPATION
Teacher (Ret'd)
26. CAUSE OF DEATH (Enter only one cause per line for (A), (B), and (C). o
DEATH WAS CAUSED BY: :
IMMEDIATE CAUSE (A)&
PART |.
TO
PHYSICIAN: DUENS
()
. KIND OF BUSINESS
25. INFORMANT — OR SOURCE
. _OF INFORMATION
B, Drne,Hutchison
OR INDUSTRY
INTERVAL BETWEEN
ONSET AND DEATH
A Aewes
/*«’/u #
Loty
>
Cenditions, if any, which gave rise
to immediate cause (A), stating the
underlying cause last.
Complete and sign
medical certification
(item 26) and return
both copies to funeral
director as soon as
possible after
determination
of cause.
DUE TO
()
PART 1.
DISEASE CONDITION GIVEN IN PART I (A)
Il
26b. IF FEMALE, WAS THERE A PREGNANCY IN PAST
3 MONTHS?
yes D no fi unknown D
26e. TIME OF INJURY
AM
P.M
26i. | CERTIFY that | attended the deceased from
1
NOTE: If
"Pending” must be
indicated, so state in
part | and notify regis-
trar of final decision
as soon as possible.
MEDICAL CERTIFICATION
ACTUAL
SIGNATURE
REMOVAL CREMATION
O O
2 (signature of funeral director or persgn acting
i,
/B
27. BURIAL ¢ :
K]
FUNERAL
DIRECTOR
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL
26c.
26f.
Y rrca tr
28. PLACE
./4'
26a. AUTOPSY?
AUTHORIZED
O
(enter nature of injury in part | or part Il)
IF EXTERNAL CAUSE, IT WAS 26d. DESCRIBE HOW INJURY OCCURRED.
PRIMARY E] or CONTRIBUTING [:I
TO CAUSE OF DEATH.
NOTE: IF EXTERNAL CAUSE, NOTIFY MED. EXAMINER
INJURY CCCURRED
while
26h. (county) (state)
1
1
I
1
PLACE OF INJURY (home, farm, (city or town)
26g.
= factory, street, office bldg., etc.)
not while
at work at work
2 2
2/ Z, éfib
® &="3nd that death occurred ol (AM) M'from' cals¢’/stated above
¢ ‘cddress — cufy and state) (dafe signed)
D)1 bl D ey 4k
(city or county) ™=
Middleburg, Va..
Royston Funeral Home
Middleburg, Virginia