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, GEORGIA OEPARTMENT OF PUBLIC NEALTH 2451~6
VITAL RECORDS SERVICE
Custodian i Na 368
' tiAM£ OF lE'int) (Middl~) lLast) DOFTE (M1oatL) (Da7) (Y~o)
; LECEASED
, ~rY,^.e or Print) Thomas Ben j amin Godl ey I D~TN AuQUSt 18, 1968
• ~:.AGE OF DEAIH (Couat~; ' USUAL SFSIDENCE (Wh~r~ d~cNS~d ~~~d. U insutuvoa: r~rd~ac~ beloi~ adauauoo)
~ Charlton I Georgia Camden ~
C~ht or Town le Ci1~ Limiu LEHGTH OF In Cit~ Limi4 iLENGTH OF
Y~~ ? Ho ~ STAY lia lLis plac~) Y~~ Q No ~ 52AY m tLi~ pAc~)
Folkston D.O.A. i~n` white Oak ~ 1~ yrs.
Nam~ ot Hosp. or testitution LEKGTH OF SU~it
Addr~ss or S.F.D. aad Dox No.
McCo Jackson Hos SlAY
Y- P• D.O.A. RFD Route 1
' SEX RACE BIaIHP1ACE (Stu~ ot touiyn coua?ry) CITIZET7 OF WtiA7 ~IDENCE ON PARM? BURIAL ~ D TE
COUNiNY7 REMOVAL p
' ;~t I W( Georq ia USA Y•• ? x° ~t i CREMATION ? Aug . 20,1968
~ i~ATE OF BIATH dGE (In yun) if UNDER 1 YFAR IF UNDER 2~ Iii1S. NAME OF CEMETEAY LOCATION (Ci~y or 7own) (Couat~) (Stat~)
f last bir~hd~Y Months D~T~ i Houn Min.
6 18 06 I 62 ~ I I ~ urnt Fort Cemetery~ Camden County, Ga.
hIF./" NEVER MARPIED ~_J II Malfl~ O[ W~dOM~ Gt~~ I'I~~ OI SpOW~ EMBALMER'S SIGNAiIIRE
K'iJOWE~' DIVORCED J R~ C. Adkins
SEPARATED[7 ~illie Mae Lott GOCi~ev
~SUAL OCCUPAiION (Cive kind ot work ;RIND OF BUSINFSS OA M09i1CIAN '
da-o dunny most o! wo~i~aq GI~. ~~~n il r~tir~d) ~NDUS7AY
Adkins Morticians
Salesman &_Bookkee~er ~Oi Distributor
'.YnS UEC~.ASED EVER IN U. S. AflME EORCFST SOCIAL SECUEITY NO. MOHTiCIAN'S ADDR~S$
iYes, no, ot unkaowa; (I! y~~. Q~?~ M~ O~ di1N OI N~t~~
I ' 263-07-1828 Folkston, Georgia
FATHER'S~ NAME IIiFOAMAHi S~Ltionship
Andrew B. Godlev Mrs. Liilie Mae Godley Wife
i MOTtiER'S MAIDEN NAME _ INFOAMADiT'S ADDHPSS
~ Maud Pacetti Route #1, White Oak, Georgia
! ::AUSE OF DEA7H [Enter oaly ou~ caus~ p~~ lia~ for (b). aad (c).j PLEASE PRINi . ~I;ITERVAL BETVIIEEN;
ONSET AND DEAZti
PART I. DEATH WlIS CAUSED IIY: M ocardial inf arction - acute
4 IMMEDIATE CAUSE (a)
F
~
~ - r-:,~;t,on,. DDE?O (b) Cardivascular disease
~ ~x-,.=5 q~.. R,. ~o
•::,q th• uaa~r•
~ : s_': ••e Cau=• t~)• - - - - - - ~ - -
:r. ~ uus~ lact. DUE TO (c)
~ PARi li. Oth~r siqni6canl toadition~ contribulinq to d~ath bu1 not r~lat~d to Ih~ t~rmind dia~u~ condit~on qi~~u in P~d i(a) ~ AlTTOPSYT
= YM r! No R
-
~ .4CCIDE:YT C PLACE OF IN)UAY (~.p.. in or about j IN)URY OCCtJRAED July
~UICIDE ~ hom~, larm. (actorY, str~H. WAiI~ at Work I h~r~bY c~AiE~ Ihal I allaad~d W~ d~cw~d Irom
iiJyS[CIDE ~ oHic~ bldq.. ~tc.1 I No1 Whi4 al Wort O 19 65 to June ~9 68 lbat ! lut s~w tL~ d~c~as~o
+,C:.-Y OA ZOWN) (COUNTY) (STATE) ' i1.RE (Mont6j
(D~~) (Yur) (Hour)
~ oF .u.. os 6/ 4 _ ~9 6
a . .~a
~ 1NIUAY d~alb occumd a~ 3:15 pm„ lrom tL~ uua~a aad on 16~ dat• stated abo~~.
HOW DID INIURY OCCUH7 ~ SIGNArtTSE D~pr~~ or T~U~
~ C. N. Cannon M. D.
~ ~A'E REC'D S`! LOCAL ~28. BEGISTBAR' S1GNA RE JlDDRFSS DATE SIGNED
~ hEG.
_ a120/6S J S Haddock Folkston, Ga. 8/19/68
~ FILEO AND RECORDEO
, ST. ROCER POITRAS lA _
State of Georg,ia • CLERK C?KCUIT COURT ~
- • RECORO YE°.1FIF0~----~
County of ~-nari i.i~ii ' s r
~ 8 4 09 PH z3
I hereby:~ertify that the foregoing is a true and correct abstract
~i . :
. o~j~i •~ts of death as snown on a pera:anerit record oi death on `,,L~51~6
•~~~i.1e..~d,~t~B office.
~ ~ . • If ~ ,
~ . . . ~ = Signed - .
~x j; •;s,: ~ Custod~an o: Vital Statistics Records
:So=
' • . i
- ~ i -
~ `~r~ Date Zss
*~3 •
;
~LS'~AI~ Y~ ~ ued 12/8/7 2
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