CERTIFICATE OF DEATH
STATE OF TENNESSEE
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF VITAL STATISTICS
Reg. Number: 2; Reg. District:
Certificate Number: 0702
Name: John Green
Residence: LaFollotte, Campbell Co.
Date of Birth: 08 Aug 1862
Place of Birth: Campbell Co. Tn.
Date of Death: 04 Feb 1941
Place of Death: LaFollotte, Campbell
Age: 78 years 5 months 27 days
Marital Status: Single
Spouse, if living:
Age of Spouse, if living:
If Veteran, Name of War:
Social Security Number: none
Industry or Business: (left blank)
Father's Full Name: Richard Green
Father's Birthplace: Sullivan, Va.
Mother's Full Maiden Name: Mary Jane
Mother's Birthplace: Sullivan, Va.
Cause of Death: Bronchial Pneumonia
If death was due to external causes, fill
in the following:
- Due to: Influenza
- Other conditions: (left blank)
- Operation?: (left blank)
- Autopsy?: (left blank)
Informant: Roy Prater
- Accident, Suicide, or Homicide: (left
- Date of Occurrence: 19
- Where did the injury occur: (left
- Did injury occur in or about home,
on farm, in industrial place, in public place?: (left
- While at work: (left blank)
- Means of Injury: (left blank)
Informant Address: LaFollotte, Tenn.
Burial, Removal, or Cremation: Burial
Date: 05 Mar 1941
Undertaker: Agee & Walters
Date Filed: 11 Feb 1941
Registrar: A.J. Heatherly
Signature: J.P. Lindsey
Submitter's Name: Billie Sue Stinnett
Submitter's Email: email@example.com
Relationship to the Deceased: Great
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