title

Campbell Death Certificate

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

 

Ballard Nelson
Reg. Number:  ; Reg. District: 3
Certificate Number: 9

Name: Ballard Nelson
Residence: Caryville, TN
Sex: Male
Race: White
Date of Birth:
Place of Birth: Don't know
Date of Death: 25 Jan 1914
Place of Death: Caryville, TN
Age: Don't Know
Marital Status: Married
Spouse, if living:
Age of Spouse, if living:
If Veteran, Name of War:
Social Security Number:
Occupation: Farmer
Industry or Business: (left blank)
Father's Full Name: Don't know
Father's Birthplace: Don't know
Mother's Full Maiden Name: Don't know
Mother's Birthplace: Don't know
Cause of Death: Bright's Disease
  • 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)
  • Date of Occurrence: 19
  • 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:
Informant Address:
Burial, Removal, or Cremation:
Date: 19
Undertaker:
Address:
By:
Date Filed: 29 Jan 1914
Registrar:
Signature:
Address:

Submitter's Name: Suzanne Pratt
Submitter's Email: swmpratt@swmpratt.com
Relationship to the Deceased: none

Comments: Source: Copy of Campbell County Death Certificate

 


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