Death Certificate of Gray, Herman Waverly

Herman Waverly Gray, age 57, was born 25 Aug 1899 in Southampton Co.,
Virginia, to Willie Gray and Dora Lee Drake. He was married and
resided at 216 Highland Ave., Suffolk, Virginia. He died 2 Sep 1956 in
Suffolk, Nansemond Co., Virginia, from acute myocardial infarction due
to coronary thrombosis and chronic coronary arteriosclerosis. His spouse
was Emma Jane Gray.

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| Field                                     | Value                                                 |
|-------------------------------------------|-------------------------------------------------------|
| Registration District No.                 | 2610                                                  |
| Registered No.                            | 51                                                    |
| Certificate No.                           | 21609                                                 |
| 1. PLACE OF DEATH COUNTY                  | Nansemond                                             |
| 1. PLACE OF DEATH CITY OR TOWN            | Suffolk                                               |
| 1. PLACE OF DEATH HOSPITAL OR INSTITUTION | No                                                    |
| 2. MAGISTERIAL DISTRICT                   | Not listed                                            |
| 3. USUAL RESIDENCE STATE                  | Va                                                    |
| 3. USUAL RESIDENCE COUNTY                 | Nansemond                                             |
| 3. USUAL RESIDENCE CITY OR TOWN           | Suffolk                                               |
| 3. USUAL RESIDENCE STREET                 | 216 Highland Ave.                                     |
| 3. USUAL RESIDENCE INSIDE CITY LIMITS     | Yes                                                   |
| 3. USUAL RESIDENCE ON A FARM              | No                                                    |
| 4. FULL NAME OF DECEASED                  | Herman Waverly Gray                                   |
| 5. COLOR OR RACE                          | White                                                 |
| 6. SEX                                    | Male                                                  |
| 7. MARITAL STATUS                         | Married                                               |
| 8. DATE OF BIRTH                          | Aug 25, 1899                                          |
| 9. AGE                                    | 57 years                                              |
| 10. USUAL OCCUPATION                      | Dairyman                                              |
| 11. KIND OF BUSINESS OR INDUSTRY          | [Blank]                                               |
| 12. BIRTHPLACE                            | Southampton Co.                                       |
| 13. FATHER'S NAME                         | Willie Gray                                           |
| 14. MOTHER'S MAIDEN NAME                  | Dora Lee Drake                                        |
| 15. NAME OF HUSBAND OR WIFE OF DECEASED   | Emma Jane Gray                                        |
| 16. INFORMANT'S SIGNATURE                 | Mrs. Emma Jane Gray                                   |
| 16. INFORMANT'S ADDRESS                   | 216 Highland Ave., Suffolk, Va                        |
| 17. SIGNATURE OF FUNERAL DIRECTOR         | No information obtained from funeral director         |
| 17. ADDRESS OF FUNERAL DIRECTOR           | I. O. Hill, Suffolk, Va                               |
| 18. CAUSE OF DEATH PART I IMMEDIATE CAUSE | Acute myocardial infarction                           |
| 18. CAUSE OF DEATH DUE TO                 | Coronary thrombosis                                   |
| 18. CAUSE OF DEATH DUE TO                 | Chronic coronary arteriosclerosis                     |
| 18. PART II OTHER SIGNIFICANT CONDITIONS  | Parkinton's disease                                   |
| 19. WAS AUTOPSY PERFORMED                 | No                                                    |
| 20. ACCIDENT, SUICIDE, HOMICIDE           | No                                                    |
| 20b. DESCRIBE HOW INJURY OCCURRED         | [Blank]                                               |
| 20c. HOUR OF INJURY                       | [Blank]                                               |
| 20d. DATE OF INJURY                       | [Blank]                                               |
| 20e. PLACE OF INJURY                      | [Blank]                                               |
| 20f. CITY, TOWN, OR LOCATION              | [Blank]                                               |
| 20g. COUNTY                               | [Blank]                                               |
| 20h. STATE                                | [Blank]                                               |
| 21. ATTENDED FROM                         | Jan 1952                                              |
| 21. LAST SAW ALIVE                        | 2 Sep 1956                                            |
| 21. DEATH OCCURRED AT                     | 3:55 a.m., 2 Sep 1956                                 |
| 22. SIGNATURE OF PHYSICIAN                | Phillip R. Thomas, MD                                 |
| 22. ADDRESS OF PHYSICIAN                  | Suffolk, Va                                           |
| 22. DATE SIGNED                           | 2 Sep 1956                                            |
| 23a. BURIAL, CREMATION, REMOVAL (Specify) | Burial                                                |
| 23b. DATE                                 | 4 Sep 1956                                            |
| 23c. NAME OF CEMETERY OR CREMATORY        | Rosewood Memorial Park Cemetery                       |
| 23d. LOCATION                             | Norfolk, Virginia, USA                                |
| 24. FUNERAL DIRECTOR'S SIGNATURE          | No information obtained from funeral director         |
| 24. ADDRESS                               | Suffolk, Va                                           |
| DATE RECEIVED BY LOCAL REGISTRAR          | 26 Sep 1956                                           |
| REGISTRAR'S SIGNATURE                     | E. Lee Everett                                        |
| 25. DATE OF TRANSIT PERMIT                | 1-30-56                                               |
| 26. REMARKS                               | No information obtained from funeral director.1-30-56 |
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