title

Campbell Death Certificate

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

 
Roscoe Holt
Reg. Number:  20704; Reg. District: 4
Certificate Number: 20704

Name: Roscoe Holt
Residence: Jellico
Sex: Male
Race: white
Date of Birth:
Place of Birth: Tenn
Date of Death: 17 Mar 1916
Place of Death: Jellico
Age: 9
Marital Status: Single
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: Noah Holt
Father's Birthplace: Tenn
Mother's Full Maiden Name: Lucinda Tye
Mother's Birthplace: Tenn
Cause of Death: Run over by automobile
  • 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: Accident
  • Date of Occurrence: 17 Mar 1916
  • 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: left blank
Informant Address: blank
Burial, Removal, or Cremation: burial Crouches Creek
Date: 18 Mar 1916
Undertaker: Ellison Funeral Home
Address: Jellico
By: blank
Date Filed: 18 Mar 1916
Registrar: Moore
Signature:
Address:

Submitter's Name: Carl Davis
Submitter's Email: ciddddavis@citlink.net
Relationship to the Deceased: distant cousin

Comments: No date of birth shown


 


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