Isle of Wight County Virginia USGenWeb Archives Vitals.....Johnson, Mary A. Holland, 1929 

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Mary A. (HOLLAND) JOHNSON, 12 June 1857 - 21 Nov 1929, death certificate 

[Official Form (printed); handwritten responses <thus>] 
Form No. 12. 
______________________________________________________________________________ 

[header] 
                              Certificate of Death 
1.  Place Of Death          Commonwealth of Virginia 
County Of <Isle of Wight>  Bureau of Vital Statistics       26922 [stamped] 
District of <Hardy>          State Board of Health 
    Or                               ____ 
Inc. Town of [blank] 
    Or                   Registration District No. <460C>  Registered No. <8> 
City of [blank]          (No. [blank]    St.          [blank]    Ward) 

2. Full Name <Mary A. Johnson> 
   (A) Residence.  No.  [blank]     St.     [blank]    Ward     [blank] 
         (Usual place of abode)   (If non-resident give city or town and State) 
______________________________________________________________________________ 
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[column 1 of 2] 
          Personal and Statistical Particulars 
______________________________________________________________________________ 
 3. Sex <Female>  4. Color or Race <White> 
 5. Single, Married, Widowed, or Divorced (write the word)  <Widowed> 
 5A. If Married, Widowed, or Divorced, 
     Husband of (or) Wife of [blank] 
 6. Date of Birth <Jan* 12,  1857> 19<[blank; form too specific]> 
 7. Age    <72> Years [blank] Months [blank] Days 
[*looks like "June" but must be Jan. to agree with age] 
 8. Occupation of Deceased 
  (a) Trade, profession, or particular kind of work <Housewife> 
  (b) General nature of industry, 
  business, or establishment in 
  which employed (or employer) [blank] 
  (c) Name of employer [blank] 
______________________________________________________________________________ 
 9. Birthplace 
    (City or Town) <Isle of Wight Co, Va.> 
    (State or Country) [blank] 
______________________________________________________________________________ 
Parents 
10. Name of Father <Holland> 
11. Birthplace of Father 
    (City or Town) [blank] 
    (State or Country) <Isle of Wight Co, Va.> 
12. Maiden Name of Mother <Nancy Johnson> 
13. Birthplace of Mother 
    (City or Town) [blank] 
    (State or Country) <Isle of Wight Co, Va.> 
______________________________________________________________________________ 
14. Informant <L.H. Johnson> 
    (Address)  <Isle of Wight Co, Va.> 
______________________________________________________________________________ 
15. Filed <Nov 22>, 19[blank]   <W.R. Hall> 
                                      Registrar 
______________________________________________________________________________ 
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[column 2 of 2] 
          Medical Certificate of Death 
______________________________________________________________________________ 
16. Date of Death <November 21,> 19<29> 
17.        I Hereby Certify, That I Attended Deceased From 
    <Jan.>, 19<26>  To  <Nov. 19>, 19<29> 
    That I Last Saw H<er> Alive On <Nov. 19,>, 19<29> 
    And That Death Occured, On Date Stated Above, At <4  a>M. 
    The Cause of Death* Was As Follows: 
      <Pulmonary Tuberculosis> 
                  <31> 
                              Duration  [blank] Yrs. [blank] Mos. [blank] Ds. 
    Contributory <Chronis Nephritis> 
      (Secondary)             Duration  [blank] Yrs. [blank] Mos. [blank] Ds. 

18. Where was disease contracted if not at place of death? <[check mark]> 
    Did an operation precede death? <No>  Date of [blank] 
    Was there an autopsy? <no> 
    What test confirmed diagnosis? <Phys. Exam -> 

         (Signed) <R Lee Seward>, M.D. 
    <11- 21->, 19<29>  (Address) <Isle of Wight Co, Va.> 
    *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 
    <Antioch Church>                           <11-22-29> 
20. Undertaker  <C. W. Bailey> 
    Address <Isle of Wight Co, Va. ["Windsor" overwritten]> 

______________________________________________________________________________ 
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[document end] 

The Library of Virginia (LVA), Richmond, VA 
   Bureau Of Vital Statistics, Death Certificate 1077-26922 

[unmarked? not on IWCHS Grave Site Survey Task Force's Antioch list] 

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/j525m1dc.txt