Isle of Wight-Southampton County Virginia USGenWeb Archives Vitals.....Johnson, G. Fred, 1928 ************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/va/vafiles.htm ************************************************ George Fred JOHNSON, 30 Aug 1848 - 15 Sep 1928, death certificate [Official Form (printed); handwritten responses ] Form No. 12. ______________________________________________________________________________ [header] Certificate of Death 1. Place Of Death Commonwealth of Virginia County Of [blank] Bureau of Vital Statistics 20978 [stamped] Magisterial State Board of Health District of ____ Or Inc. Town of Or Registration District No. <460a> Registered No. <8> City of [blank] (No. [blank] St. [blank] Ward) 2. Full Name (A) Residence. No. [blank] St. [blank] Ward [blank] (Usual place of abode) (If non-resident give city or town and State) ______________________________________________________________________________ ŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻ [column 1 of 2] Personal and Statistical Particulars ______________________________________________________________________________ 3. Sex 4. Color or Race 5. Single, Married, Widowed, or Divorced (write the word) 5A. If Married, Widowed, or Divorced, Husband of (or) Wife of 6. Date of Birth 19[overwritten; form too specific] 7. Age <80> Years [blank] Months <16> Days 8. Occupation of Deceased (a) Trade, profession, or particular kind of work [blank] (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer [blank] ______________________________________________________________________________ 9. Birthplace (City or Town) (State or Country) ______________________________________________________________________________ Parents 10. Name of Father 11. Birthplace of Father (City or Town) [blank] (State or Country) 12. Maiden Name of Mother 13. Birthplace of Mother (City or Town) (State or Country) [blank] ______________________________________________________________________________ 14. Informant (Address) ______________________________________________________________________________ 15. Filed , 19<28> Registrar ______________________________________________________________________________ ŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻ [column 2 of 2] Medical Certificate of Death ______________________________________________________________________________ 16. Date of Death 19<28> 17. I Hereby Certify, That I Attended Deceased From , 19<28> To , 19<28> That I Last Saw H Alive On , 19<28> And That Death Occured, On Date Stated Above, At <9 A>M. The Cause of Death* Was As Follows: <185D> <[check mark] (over) Duration [blank] Yrs. [blank] Mos. <4> Ds. Contributory (Secondary) Duration [blank] Yrs. [blank] Mos. [blank] Ds. 18. Where was disease contracted if not at place of death? [blank] Did an operation precede death? [blank] Date of [blank] Was there an autopsy? [blank] What test confirmed diagnosis? [blank] (Signed) , M.D. , 19<28> (Address) *State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCI- DENTAL, SUICIDAL, or HOMICIDAL. ______________________________________________________________________________ 19. Place of Burial, Cremation or Removal Date of Burial [blank] 20. Undertaker Address ______________________________________________________________________________ ŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻŻ [reverse; roughly trimmed and pasted to back of certificate; seems to be typed (except for letterhead); handwritten responses ] Bureau of the Census Richmond, Va. Washington <11/1/28> Dear Doctor: In order to classify intelligently causes of death it is essential that we have the most specific information obtainable. We therefore request that you supply us with any additional information that you may have relative to the following case. Items lacking are indicated by check marks. who died at [blank] cause of death is given as Contributory cause: [document end] The Library of Virginia (LVA), Richmond, VA Bureau Of Vital Statistics, Death Certificate 1928-1002-20978 [**Cemetery list gives wife as Bettie P. Johnson (9-28-1876 - 1-24-1976). Southampton County Historical Society {SCHS} Cemetery Project, Tucker Swamp list (TS-23): http://files.usgwarchives.net/va/southampton/cemeteries/tckrswp.txt Contributed for use in USGenWeb Archives by: Matt Harris (Zoobug64@aol.com) [brackets & capitalization mine]. file at: http://files.usgwarchives.net/va/isleofwight/vitals/deaths/j525g1dc.txt