Colored Teacher, Death Certificate, Alice M. Scott, Bluemont
Place
Virginia
Identifier
1023544
Is Version Of
1023544_EWP_Scott_Alice_of_Bluemont.jpg
1023544_EWP_Scott_Alice_of_Bluemont.pdf
Is Part Of
Uncategorized
Date Created
2024-07-29 17:32:05 +0000
Format
PDF Document
Pdf Document
Publisher
Digitized by Edwin Washington Project
Digitized by Edwin Washingon Project
Rights
Loudoun County Public Schools
Language
English
extracted text
- i49
1 PLACE OF DEATH ' 0 S SRR v @'WQS
z ) | CERTIFICATE OF DEATH
COUNTY OF A R L COMMONWEALTH OF VIRGINIA
BUREAU OF VlTAL STATISTICS
MAGISTERIAL
DISTRICT OF STATE BOARD OF HEALTH
OR 2
INC. TOWN OF REGISTRATION DISTRICT NOQZ_M?EGISTERED No._ »~8J é
FOR USE OF LOCAL RIGIBTRAR)
OR
CITY OF il il oS i R 1 LI PRt e MR St AR ST L 3 ST. .. _WARD)
2 FULL NAME
(A) REsIDENCE. _ No. ST., WARD; g il IS s e
(Usual place of abode) (If non-resident give city or town and State)
Length of residence in city or town where death occured yIs. 2 O mos. ds. How long in U. S., if of foreign birth? yrs. mos. ds.
PERSCNAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE|5 SINGLE, MARRIED, WIDOWED.
OR DIVORCED (write the word)
___L@‘Q_me_»g‘f_: = =
1 HEREB CERTIFY THAT I ATJTENDED DECEASED FROM
5A IF MARRIED, WIDOWED, OR DIVORCED
HE SN DT s '
(or) WIFE OF é\ 1927
16 DATE OF DEATH (MONTH, DAY, AND YEAR, WRITE NAME OF MONTH)
6 DATE OF BIRTH (MONTH, DAY, AND YEAR, WRITE NAME OF MONTH) L1982
T oo - 19
7 AGE MONTHS ‘ DAYS IF LESS THAN
THIS IS A PERMANENT RECORD. EVERY
AND THAT DEATH OCCURED, ON DATEASTATED ABOVE, AT#M.
THE CAUSE OF DEATH* WAS As FOLLOWS;
-
é OR MIN,
8 OCCUPATION OF DECEASED
(A) TRADE, PROFESSION, OR G é I ‘2 ééi ‘2
PARTICULAR KIND OF WORK
(B) GENERAL NATURE OF INDUSTRY.
BUSINESS, OR ESTABLISHMENT IN
WHICH EMPLOYED (OR EMPLOYER)
(c) NAME OF EMPLOYER l\M %"VV\WU& _&#j . 5M 2
9 BIRTHPLACE CONTRIBUTORY.
(SECONDARY)
(c1TY OR TOWN)
(DURATION)
(STATE OR COUNTRY) 18 WHERE WAS DISEASE CONTRACTED
10 NAME OF FATHE IF NOT AT PLACE OF DEATH?
“l/b&’g IDeia_eoen
11 BIRTHPLACE OF FATHER DID AN OPERATION PRECEDE DEATH ?
1 DAY, HRS
MARGIN RESERVED FOR BINDING
(ciTY OR TOWN) WAS THERE AN AUTOPSY?
(STATE OR CO_L_!NTRY)
12 MAIDEN NAME OF MOTHER ?i Z
13 BIRTHPLACE OF MOTHER T%
(c1ry or Town) ——*fi‘M—m State the DISEASE. CAUSING DEATH, of in deaths from VIOLENT CAUSES,
H, oL
ate (1) MEANS AND NATURE OF INJURY. and (2 :
S(sTaTE on counTRx)Ri T IR DR e e S BENTAL, SUICIDAL, or HOMICIDAL, and (2) whether ACCI-
m
19 PLACE OF BURIAL, CREMATION, OR RE-| DATE OF BURIAL
MOVAL
PARENTS
14 INFORMANT L
/A Y EN 7
pooress) ALLYL Al 22o0228 —CF
B &
e T o 2 E 5
; REGISTRAR ADDRESS :