Nansemond-Isle of Wight County Virginia USGenWeb Archives Vitals.....Dunston, Emmeline Bradshaw, 1931 ************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/va/vafiles.htm ************************************************ Emmeline (BRADSHAW; Mrs. T. Julius) DUNSTON, d. 19 Aug 1931, death certificate [Official Form (printed); handwritten responses ] [instructions printed along margin] Form V. S. No. 12--2-28-25.[?] Margin Reserved for Binding N.B.=Write Plainly, With Unfading Ink (Writing Fluid) This Is A Permanent Record. Every item of information should be carefully supplied. Age should be stated Exactly. Physicians should state Cause Of Death in plain terms, so that it may be properly classified. Exact statement of Occupation is very important. (See instructions on back of certificate.) ______________________________________________________________________________ [header] 1. Place Of Death Certificate of Death County Of Commonwealth of Virginia 19679 [stamped] Magisterial Department of Health District of [blank] Bureau of Vital Statistics Or ____ Inc. Town of [blank] Registration District No. <2610> Registered No. <219> Or (To Be Inserted By Registrar)-(For Use of Local Registrar) City of (No. <127 Military Road> St. <3> Ward) (If death occurred in a hospital or other institution, give its Name instead of street and number) Length of residence in city or town where death occurred [blank] yrs. [blank] mos. [blank] ds. How long in U.S., if of foreign birth? [blank] yrs. [blank] mos. [blank] ds. 2. Full Name (A) Residence No. <127 Military Road> St. <3> Ward [blank] (If nonresident give city or town and State) ______________________________________________________________________________ [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 [blank] 6. Date of Birth (month, day, and year) 7. Age <70> Years <5> Months <4> Days If Less Than 1 Day, [blank] hrs. or [blank] min. Occupation 8. Trade, profession, or particular kind of work done, as Spinner, Sawyer, Bookkeeper, Etc. 9. Industry or business in which work was done, as Silk Mill, Saw Mill, Bank, Etc. [blank] 10. Date deceased last worked at this occupation (month and year) [blank] 11. Total time (years) spent in this occupation [blank] 12. Birthplace (city or town) [blank] (State or country) Father 13. Name 14. Birthplace (city or town) [blank] (State or country) Mother 15. Maiden Name 16. Birthplace (city or town) [blank] (State or country) 17. Informant (Address) 18. Burial, Cremation, or Removal , 1<931> 19. Undertaker Address 20. Filed , 1<931> Registrar. ______________________________________________________________________________ [column 2 of 2] Medical Certificate of Death 21. Date of Death , 1<931> 22. I Hereby Certify, That I attended deceased from , 1<931> to , 1<931> that I last saw h alive on , 1<931> Death is said to have occurred, on the date stated above, at <6:30 P>M. The Principal Cause of Death and Related Causes of Importance in Order of Onset were as follows: Date of Onset <[check mark]> [blank] Contributory Causes of Importance Not Related ot Principal Cause: <[check mark]> <92a> Name of Operation Date of [blank] What test confirmed diagnosis? Was there an autopsy? 23. If Death was due to External Causes (Violence) Fill in Also the Following: Date of Accident, Suicide, or Homicide? [blank] Injury [blank] , 1[blank] Where did injury occur? [blank] (Specify city or town, county, and State) Specify whether injury occurred in industry, in home, or in public place [blank] Manner of Injury [blank] Nature of Injury [blank] 24. Was disease or injury in any way related to occupation of deceased? If so, Specify [blank] (Signed) , M.D. (Address) ______________________________________________________________________________ [document end] The Library of Virginia Bureau Of Vital Statistics, Death Certificate 1189-19679 Contributed for use in USGenWeb Archives by: Matt Harris, Zoobug64@aol.com (Apr 2010) [brackets, line breaks mine]