a. Z North C
Raieigh
N.Q
Doc.
Multiple Conditions
Present at Death:
A SPECIAL STUDY
Typ«. o* P"«i f Njmi o' 5S5553 I «'
in p«i(nintnl JOHN
NORTH CAROLINA DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES - VITAL RECORDS BRANCH
CERTIFICATE OF DEATH
JUL l o 1907
Q.
miTE
u s » «..• 1 n
,. N.C.
>. 6..tn-do
HOPE
N.C.
1 01 wnji 1.0
USA
niy 01 Bl>t
HOPE
UNIONTOWN
HOPE
123-45-6789
I IB*.
Gat. ol Birin
. JULY 4,1906
D»t« o' Dum "mo»'i
JULY 4, 1976
70
HOPE (2NERAL HOSPITAL
UNIONTO.*!
JT"iJ4ER RM
Si'Hi *no NumDii in w f .D. 4 So
„ 1 ELM STREET
Su'vivinj ipoul* [H W.I*. O'X M|i«n Njm||
.YES
mild* City
Kind ol Rutmm or Indutl-y
14B TEXTILE
vi. i-L*.
r,"No"
luuiTofi 10 BSBm
lib.
DEATH CAUSED E
n . .,^l. BBSS.
ENTER ONLY ONE CAUSE PER LINE FOR («), lb). IP !»«—«" o»m »« P-um
Comjnioni, If Iny
-: M*« rlM IO
immiolJH ....» ti.
(«) ImmMnHQW; CARDIAC ARREST
MYOCARDIAL INFARCTION
I 1 cont.guanta ol
(c) Dut 10. or a, • conuqun
CINERALIZED ARTERIOSCLEROSIS
PART 11. Otnar Significant Conduit
?0, HYPERTENSION
ntrlbutlno to Daatn but not ralat.d t
DIABETES MELLITUS
YES NO
Wi* Q$\* • elf.r.id to Mudlcil tumin«i 1
.. NO
Tim* ol D«*1h
7:07 p
NOTICE STATE LAW REQUIRES THAT ALL DEATHS DUE TO TRAUMA, ACCIDENT, HOMICIDE. SUICIDE, OR UNDER SUSPICIOUS.
UNUSUAL. OR UNNATURAL C I RCUMST ANCF S BE REPORTED TO. AND CERTIFIED Bv A MEDICAL EXAMINER ON A MEOICAL EX*
AMINCR'S CERTIFICATE OF DEATH. ANY DEATHS FALLING INTO THESE CATEGORIES IS WITHIN THE MEOICAL EXAMINER'S
JURISDICTION REGARDLESS OF THE LENGTH OF SURVIVAL FOLLOWING THE UNDERLYING INJURY.
'nMiM »fid T.n« 01 c*'iii>«' (type c
HENRY ROE, MC 101 MAIN STREET UNIONTOVW, NC
fhrC *>nfr
7-7-76
Nj"i« Of ' •"•>!•' v <W 1 .r."»i ,1 v
MEMORIAL PARK
UNIONTCWJ, NC
tf&JMtLe.
Data SignaO
JULY 5, 1976
gjd.
UNIONTOWN NC
Slonatu.a ot F unarai D>aa<to>
aJL.
Signji.jn ol E*tib*li M (W^mb^lm^or 333 LKInU NO.
9£Q
State Center for Health Statistics
Division of Health Services
N.C. Department of Human Resources