STATE OF TENNESSEE
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF VITAL STATISTICS
Reg. Number: 162; Reg. District: 40701
Certificate Number: 9610
Name: Preston Goins
Residence: LaFollette RuralTenn. Campbell County
Date of Birth: 27 May 1858
Place of Birth: Campbell County Tenn.
Date of Death: 24 Feb 1948
Place of Death: LaFollette Tenn.
Marital Status: Widowed
Spouse, if living: Blank
Age of Spouse, if living:
If Veteran, Name of War: Blank
Social Security Number: Blank
Industry or Business: (left blank)
Father's Full Name: Milton Goins
Father's Birthplace: Campbell Co. Tenn.
Mother's Full Maiden Name: Phoebe Smith
Mother's Birthplace: Tenn.
Cause of Death: MyoCarditis; Acute edema
If death was due to external causes, fill in the following:
- Due to: Old Age; Nephritis
Other conditions: (left blank)
Operation?: (left blank)
Autopsy?: (left blank)
Informant: Bill Goins
- 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 Address: LaFollette Tenn.
Burial, Removal, or Cremation: Fincastle, LaFollette Tenn.
Date: 26 Feb 1948
Date Filed: 05 Jun 1948
Registrar: Elise P. Jones
Signature: Elise P. Jones
Submitter's Name: Pam Shown
Submitter's Email: email@example.com
Relationship to the Deceased: Cousin
Comments: Cannot read Doctor's
name or the undertaker
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