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BUREAU
OF VITAL STATISTICS
PLACE OF DEATH
County GARZA
City TEXAS
FULL NAME Samuel Smith House
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3. SEX
MALE
4. COLOR OR RACE White
5. Marital Status Married |
16. Date
of Death October 5, 1918 |
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6. Date of
Birth August 17, 1855 |
17. I HEREBY
CERTIFY, That I attended the deceased from Oct.
3, 1918
, to Oct. 5, 1918
, that I last saw alive
on , and that death occurred, on the date stated
above, at 11p
m.
The CAUSE OF DEATH* was as follows: |
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7.
Age
63
yrs. 1
mos. 19
days |
Broncho Pneumonia
Duration 3 days |
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8. Occupation
Farmer |
Contributory |
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9. Birthplace
Georgia |
(signed)
O.L. Thweatt |
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10. Name of Father Samuel
Smith House |
(Address)
Post, Texas |
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11, Birthplace of
Father Georgia |
18. LENGTH OF
RESIDENCE (For Hospitals, Institutions, Transients, or Recent
Residents.) |
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12. Maiden Name Mother
Margaret England |
19. PLACE OF
BURIAL OR REMOVAL Post, Texas |
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13. Birthplace of
Mother Georgia |
DATE OF
BURIAL October 6, 1918 |
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14. THE ABOVE IS TRUE TO
THE BEST OF MY KNOWLEDGE
Informant: Katy House
Address: Post, Texas |
UNDERTAKER
M.Z. Mason |
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15. Filed
October 5, 1918
Ira Weakley,
Registrar |
ADDRESS:
Post, Texas |
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