title

Campbell Death Certificate

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

 

Jerrie Nelson
Reg. Number:  4381; Reg. District:
Certificate Number:

Name: Jerrie Nelson
Residence: Campbell TN
Sex: Male
Race: White
Date of Birth:
Place of Birth: Campbell
Date of Death: 07 Aug 1910
Place of Death: Campbell
Age: 3 months
Marital Status: Single
Spouse, if living: none
Age of Spouse, if living:
If Veteran, Name of War:
Social Security Number:
Occupation: none
Industry or Business: (left blank)
Father's Full Name:
Father's Birthplace:
Mother's Full Maiden Name:
Mother's Birthplace:
Cause of Death: not known
  • 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: Dr. W.B. Rose
Informant Address:
Burial, Removal, or Cremation:
Date: 19
Undertaker:
Address:
By:
Date Filed: 08 Aug 1911
Registrar: Jno. .E. Brown
Signature:
Address:

Submitter's Name: Suzanne Pratt
Submitter's Email: swmpratt@swmpratt.com
Relationship to the Deceased: distant cousin

Comments: source: Copy of Campbell County Death Certificate

 


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