HomeMy WebLinkAbout0475 3,, I Registtatioa Dist. No.-s~l-A CERTiFICATE OF DEATH 1~r ,~~285$
~ Rcgisdar
s No6 5 0 O 4 7 0 0 Vitat Sbtistia--StaM Board of Heakh
Birth Na. So~h C.arobnt State File No.
5
~ $ ~ a. COUNTI?D • instatu4oa:
E~ S u m t e r ~srwz~s~O°~ F lm oovrrri S t. L u c i e
b. C1TY, TOWN. OR LOCATION a~
1GPH OF STAY c. CiIY. TOWN. OR I.O('.ATIO~I
Sumter ~ Fort P`ierce. Fla:~ ~ ~i
°i d. NAME OF (It mt in hoepihl, pve s~eet a~nm) d. STREEC ADDR&SS
INSTptl'[Tl'IUN T u o m e H O S
y pital 2715 Placid Ave.
~ i e. IS PI.ACE OF DEATH INSIDB C1TY I,dMI'I'S? e. ~~IDENC~ INSIDB CI1Y f. A RFSRID~ffidCg ON
7fES NO YES NO YES NO
, 1 ~ DECEAS~ ~ - ~ OF ~ O° Y e~r
~w ~ cr,-aor~ Lillian Sprott Griffy D~?'r~ 3/9/1965
o~ i SEX G. COLOR 7. blARRIED~] NfiYER 8. Date aE Birth 9. AGS (In II Ur?dx 1 Yr. If Under 44 H~s.
C~ ° U F e m a 1 ei oa tu i t e ~D O~ ~c e~~' ara n.ry xo~ n~o.
e I I_ ~ ~ zvinowEn ? nrvoscsn p ~ S/ 12 / 19 ~ 1 3 3 ~ ~
' q~ 10~. USUAL OOCUP~TION (Cive kind of ~ lOb. HI~'D OF BUSINESS 11. BIRT~PL!?CE (Shts or 14, (TfrZgDi pg
~~~~s wo~t dooe during most of working OR INDUSTRY oamtr7) WHAT COUNIRY?
i c_~~ ~ n~~ De u~ Re istrar I S~.
' ~ U o I 13a. F ER'S N • M v -
j ~a=o~~ John Webb Sprott Minnie Sue Sauls ~ Gene Davis riffy
y
~ ~ zxs ~ - 1 DE E.1S E~ \ RJ! F ? 18. S . , p~
Q~7 ~ a~ ~(Yes. n0. or unknowv) (II Yes. S~ wu or dates oE se:~ ice~
~ ~~~~l~ Mrs. rances S.Reynolds
i W ~ ~ TtVEEN ONSSP
18. CAUSE OF DEATH (EoEer ont~ me caase per Line fm (a). (b), and (c).] AND DEATH
f W 0.~~I PART I. DEA7'fi WAS CAUSED BY:
! aea~.,!~ ~ca~mU~ cr~vsg ca) Carc inoma of breas t wi th extensi e
~~.~~r, metastases year
, (~v~ <7. a~icL g~re rise w DUE TO (bT----------
: qtY~O ~ x above nuse (a),
O stating the aoder-
y~~o~.i~ t ~>1Og a~se lut. D[1E TO (cI-~._ - -
~s~,~ V PAR'f U. OTfiER SIGh'IFICANf COV'D1TIOtiS CO\TRIBUTING TO DEATH BUT 1~dT RELATED TO THS 19. WAS AUTOPSY '
U~~ ~ 'I'ER~fINAL DISEASE QONDrPION C1VEY IX PART I(a) pgpgpp~~gpt
Yffi NO
' x'8o ~i N Oa. ACCID~T SUICIDE HO~iiCIDE ~£Ob. DESCRIBfi HOW INJURY OOCIIRRED. (Enter naturc of ia' O
~ ~ A~~„ ~ Q a ~nty in Part I or Part II vf item 18.)
~ ~~~W E? t 20c. I~~iJgYF H~ 2~lnnth. D~Y. Year ~
i C~"` G7 p,m,
: ~ YOd. INJURY OOCURRED f 20~. YI.ACB OF INJtTRY (e. s., in or abont 20f. C1TY, TOW~T, OR I.OCATION
~ Wh~7e at Not W6[le ~ b~. f~m. factory. strcet. o~Hice bld;.. ~~Y Stats
; i 4) ~ «t o.: ~cmt p, ~e~a j -
o`l ~ 1. I attended t6e dcoe~scd fmm 9 6 5 3 9 6 5 ~ 3 R 6 S
R• O S AM '~0--------and iast ow h~ ain.e on_
~ z: .
DeatL occorred at._ _~~-----,____.m. m tLe date stated abov~: and to tbe best of my koowkdgq hom the canses shted.
~ ! ~ta. SIGNAT'URE (De~ee or title) ~ Y4b. ADDRESS
24c. DAT6 SIGNSD
~ ~~°i~~i Lea B.Givens MD
~ s.~~ " ~ URI L b. DATS . C ~ey. towu. or co~wtY
' B~S~ ~~tov~i~N 3/10/65 Manning Cemetery Manning _ S.C
~ I~ aj 44. FU:~£IiA'L DIREC'iOR'S SICNA'I'iJAE Addras 45. DATR RECD. 48. REGISTRAR'S SIGNAT~JRS
z.g~~~ _ Sheiley Brunson,Sumter,S.C.I B~~Q~~~bS ~ E.A.Heise,MD
DEY,1F'I11F.\T OF H6ALTH, EDUCATION, AND V?~LFAAE-Pablic Health Service Form SBH-67o-25tif-2-2g-83
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