title

Campbell Death Certificate

CERTIFICATE OF DEATH
STATE OF TENNESSEE
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF VITAL STATISTICS

 

George Douglas
Reg. Number:  40705; Reg. District:
Certificate Number: 2388


Name: George Douglas
Residence:
Sex: Male
Race: White
Date of Birth:
Place of Birth: Tenn.
Date of Death: 11 Jan 1931
Place of Death: Anthras, Tenn
Age: 39
Marital Status: Married
Spouse, if living: Flossie Douglas
Age of Spouse, if living:
If Veteran, Name of War:
Social Security Number:
Occupation: Mining
Industry or Business: (left blank)
Father's Full Name: Andy Douglas
Father's Birthplace:
Mother's Full Maiden Name: Lizzie Baird
Mother's Birthplace:
Cause of Death: Bilateral pyo-hydro nephrosis
  • Due to: (left blank)
  • Other conditions: (left blank)
  • Operation?: (left blank)
  • Autopsy?: (left blank)
If death was due to external causes, fill in the following:
  • Accident, Suicide, or Homicide: (left blank)
  • Date of Occurrence: 19
  • Where did the injury occur: (left blank)
  • Did injury occur in or about home, on farm, in industrial place, in public place?: (left blank)
  • While at work: (left blank)
  • Means of Injury: (left blank)
Informant: Hazel Douglas
Informant Address: Anthras, Tenn.
Burial, Removal, or Cremation: Oswego, Tenn.
Date: 12 Jan 1931
Undertaker: Ray Ellison
Address: Jellico, Tenn
By:
Date Filed: 19
Registrar:
Signature:
Address:

Submitter's Name: Gwen Trivett
Submitter's Email: gwentrivett@bellsouth.net
Relationship to the Deceased: G-g-grand daughter

Comments: The death certificate lists his birth as Tennessee (truncated)

 


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