Death Certificates

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

Sill Vester Adams
Reg. Number:  Left Blank; Reg. District: 44301
Certificate Number: 24481

Name: Sill Vester Adams
Residence: Waverly, Humphreys County, TN.
Sex: Male
Race: White
Date of Birth: 15 Sep 1871
Place of Birth: Stewart County,
Date of Death: 19
Place of Death:
Age:
Marital Status: Married
Spouse, if living:
Age of Spouse, if living:
If Veteran, Name of War:
Social Security Number:
Occupation:
Industry or Business: (left blank)
Father's Full Name:
Father's Birthplace:
Mother's Full Maiden Name:
Mother's Birthplace:
Cause of Death:

• 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:
Informant Address:
Burial, Removal, or Cremation:
Date: 19
Undertaker:
Address:
By:
Date Filed: 19
Registrar:
Signature:
Address:

Submitter's Name:
Submitter's Email:
Relationship to the Deceased:

Comments:

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