Edwin Washington Project

EWP 4-4 Alice Hutchison Death 01

Item

Title

EWP 4-4 Alice Hutchison Death 01

Description

Death Certificate

Tag

White Teacher, Death Certificate

Place

Virginia

Identifier

1020973

Is Version Of

1020973_EWP_Hutchison_Alice_Death_01.jpg

Is Part Of

Petitions

Date Created

1/7/24

Format

Jpeg Image

Number

dad34b5b2dba81bdab83494e02963b2a4211b5f6c9226958ec717a5301820369

Source

/Volumes/T7 Shield/EWP/Elements/EWP_Files/Access Files/Upload temp/1020973_EWP_Hutchison_Alice_Death_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_Hutchison_Alice_Death_01.jpg

extracted text

MARGIN RESERVED FOR BINDING

-
5
o
£
34
€8
59
x o
~
[
o
o
£ 2
> O
o 9
a2
8l o
=
-l O
El=
9 o
=2
O o
2|
< E
S
= &=
z0
.2
o E
o >
© a
- =
£ .9
8 G
o=
o o
S
o 2
£ e
o
e
9
9
c 0
= >
e @
0o
2 c
o]
2
38
3 9
5 2
25
=) 1=
g
o E
ZD
e
'&U
C e
a @2
=
=E

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

s

(state)

M. D.

-i/&v/f* 1.,.

(name cof cemetery or cremafory)

Sharon

NAME OF FUNERAL
HOME AND
ADDRESS:

OF BURIAL,
REMOVAL, ETC.

as such)



REGISTRAR /s :

S

Cé;e(

DATE RECORD
FILED:




Item sets

EWP 04 Faculty Staff and PTAs