Campbell County Death Certificates

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

 
William Jordan
Reg. Number:  ; Reg. District:
Certificate Number: 78-036809

Name: William Jordan
Residence: Duff, Campbell Co. TN
Sex: Male
Race: white
Date of Birth: 01 Nov 1896
Place of Birth: TN
Date of Death: 09 Nov 1978
Place of Death: LaFollette, TN
Age: 82
Marital Status: Married
Spouse, if living: Virginia Hays
Age of Spouse, if living:
If Veteran, Name of War: service in armed forces marked yes
Social Security Number: 403-05-4262
Occupation: Retired Miner
Industry or Business: Industry
Father's Full Name: George Jordan
Father's Birthplace: not listed
Mother's Full Maiden Name: Rachel Baird
Mother's Birthplace: not listed
Cause of Death: ASHD with CHF, secondary to COPD
  • Due to: Polycythemia, secondary to COPD
  • Other conditions: Bronchopneumonia
  • Operation?: (left blank)
  • Autopsy?: Yes
If death was due to external causes, fill in the following:
  • Accident, Suicide, or Homicide: (left blank)
  • Date of Occurrence:
  • 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: Virginia Hays Jordan
Informant Address: Rt. 1 Duff, TN
Burial, Removal, or Cremation: Woodlawn Cemetery
Date: 11 Nov 1978
Undertaker: Fannalea Cross
Address: 301 E. Central LaFollette, TN
By:
Date Filed: 14 Dec 1978
Registrar: Sheila M Smith
Signature: Sheila M Smith
Address: not listed

Submitter's Name: Lisa Stephens
Submitter's Email: baronpool@earthlink.net
Relationship to the Deceased: distant cousin

Comments:



 


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