Death Certificate of Forrest, Edward Daniel

Edward Daniel Forrest, age 84, was born 16 Dec 1877 in Germany to John
and Annie Forrest. A resident of Sedley, Southampton, Virginia, he was
married and his spouse was Willie Francis Godwin Forrest. He died 8 Jun
1962 in Sedley, Southampton, Virginia, from a coronary occlusion.

------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------
| Field                                                  | Value                                |
|--------------------------------------------------------|--------------------------------------|
| 1. FULL NAME OF DECEASED                               | Edward Daniel Forrest                |
| 2. SEX                                                 | Male                                 |
| 3. DATE OF DEATH                                       | June 8 1962                          |
| 4. AGE OF DECEASED                                     | 84                                   |
| 5. IF UNDER 1 YEAR                                     | [Blank]                              |
| 6. COLOR OR RACE                                       | White                                |
| 7. NAME OF HOSPITAL OR INSTITUTION OF DEATH            | [Blank]                              |
| 8. COUNTY OF DEATH                                     | Southampton                          |
| 9. CITY OR TOWN                                        | Sedley                               |
| 10. INSIDE CITY OR TOWN LIMITS?                        | X                                    |
| 11. STREET ADDRESS OR R.F.D. NO. OF PLACE OF DEATH     | [Blank]                              |
| 12. STATE OR FOREIGN COUNTRY OF DECEDENT'S RESIDENCE   | Virginia                             |
| 13. COUNTY OF RESIDENCE                                | Southampton                          |
| 14. CITY OR TOWN OF RESIDENCE                          | Sedley                               |
| 15. INSIDE CITY OR TOWN LIMITS?                        | X                                    |
| 16. STREET ADDRESS OR R.F.D. NO. OF RESIDENCE          | [Blank]                              |
| 17. NAME OF FATHER OF DECEASED                         | John Forrest                         |
| 18. MAIDEN NAME OF MOTHER OF DECEASED                  | Annie Forrest                        |
| 19. CITIZEN OF WHAT COUNTRY                            | USA                                  |
| 20. MARITAL STATUS                                     | Married                              |
| 21. NAME OF SPOUSE                                     | Willie Francis Godwin Forrest        |
| 22. DATE OF BIRTH                                      | December 16, 1877                    |
| 23. BIRTHPLACE                                         | Germany                              |
| 24. OCCUPATION                                         | Foreman                              |
| 25. KIND OF BUSINESS OR INDUSTRY                       | Railroad                             |
| 26. INFORMANT OR SOURCE OF INFORMATION                 | Mrs. E.D. Forrest                    |
| 27. VETERAN STATUS                                     | [Blank]                              |
| 28. IF FEMALE, WAS THERE A PREGNANCY IN PAST YEAR      | [Blank]                              |
| 29. IF EXTERNAL CAUSE, IT WAS                          | [Blank]                              |
| 30. DESCRIBE HOW INJURY OCCURRED                       | [Blank]                              |
| 31. PLACE OF INJURY: AT HOME, FARM, STREET, ETC.       | [Blank]                              |
| 32. COUNTY                                             | [Blank]                              |
| 33. TOWN OR CITY                                       | [Blank]                              |
| 34. STATE                                              | [Blank]                              |
| 35. KIND OF PLACE                                      | [Blank]                              |
| 36. CAUSE OF DEATH                                     | Coronary Occ                         |
| 37. DUE TO                                             | [Blank]                              |
| 38. INTERVAL BETWEEN ONSET AND DEATH                   | [Blank]                              |
| 39. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH | [Blank]                              |
| 40. AUTOPSY                                            | No                                   |
| 41. ACTUAL SIGNATURE                                   | [Signature]                          |
| 42. DATE SIGNED                                        | 11-16-1957, 6-7-62                   |
| 43. REMOVAL, CREMATION, BURIAL                         | Burial                               |
| 44. PLACE OF BURIAL, CREMATION, REMOVAL                | Rosemont Cemetery, Sedley, Virginia  |
| 45. NAME OF FUNERAL HOME                               | W.J.M. Holland & Sons, Franklin, Va. |
| 46. REGISTRAR                                          | [Illegible]                          |
| 47. DATE FILED                                         | 6/13/62                              |
-------------------------------------------------------------------------------------------------