CERTIFICATE OF DEATH
STATE OF TENNESSEE
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF VITAL STATISTICS
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Lois Jean Massengill
Reg. Number: 23; Reg.
District: 73
Certificate Number: 10313
Name: Lois Jean
Massengill Residence: District 3,
Jacksboro, Campbell County, TN. Sex:
Female Race: White
Date of Birth: 11 May 1941 Place of Birth: Tennessee Date of Death: 11 May 1941 Place of Death: District 3, Jacksboro, Campbell
County, TN. Age: 3 hours and 30
minutes Marital Status:
Single Spouse, if living:
None Age of Spouse, if living:
If Veteran, Name of War:
Social Security Number: Left Blank
Occupation: None Industry or Business: (left blank) Father's Full Name: Claude Massengill
Father's Birthplace: Tennessee
Mother's Full Maiden Name: Dora
Terry Mother's Birthplace:
Tennessee Cause of Death:
Prematurity - 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)
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Date of Occurrence:
19
- Where did the injury occur: (left
blank)
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Did injury occur in or about home, on farm,
in industrial place, in public place?: (left blank)
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While at work: (left blank)
- Means of Injury: (left blank)
Informant: Mr. Claude Massengill
Informant Address: Jacksboro, Campbell
County, TN. Burial, Removal, or
Cremation: Raines Grove, Campbell County, TN. Date: 12 May 1941 Undertaker: Martin Funeral Home Address: Lake City, Tennessee By: Paul Martin Date
Filed: 03 Jun 1941 Registrar:
J.A. Nelson Signature: A. A.
Baird, M.D. Address: Caryville,
Tennessee Submitter's Name: Melissa
Barker
Submitter's Email: kaitysmom@peoplestel.net
Relationship to the Deceased: None
Comments: If anyone would like a copy of
this original death certificate, please contact me.
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