Death Certificate of Holloway, Molly A

Narrative summary of the form data:

Mollie A Holloway, age 69, was born on 13 Jun 1853 in Southampton Co.,
Va., to Henry D. Bailey and Martha B. Hart. She resided at No. 24 Main, 
Ettrick, Va., and was the widow of John J. Sullivan. She died of chronic
nephritis on 25 Dec 1922 in Chesterfield, Matoaca, Va.

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| Field                                                     | Value                            |
|-----------------------------------------------------------|----------------------------------|
| 1. PLACE OF DEATH                                         | Chesterfield, Matoaca, Va.       |
| 2. FULL NAME                                              | Mollie A Holloway                |
| (A) RESIDENCE                                             | No. 24 Main, Ettrick             |
| Length of residence in city or town where death occurred  | 12 yrs.                          |
| 3. SEX                                                    | F                                |
| 4. COLOR OR RACE                                          | White                            |
| 5. (A) MARRIED, WIDOWED, OR DIVORCED                      | Widow                            |
| 5. (B) HUSBAND OF (OR) WIFE OF                            | Theophuis Holloway               |
| 6. DATE OF BIRTH (MONTH, DAY, AND YEAR)                   | June 13, 1853                    |
| 7. AGE                                                    | 69 yrs. 6 mos. 12 ds.            |
| 8. OCCUPATION OF DECEASED                                 | At home                          |
| 9. BIRTHPLACE                                             | Southampton Co. Va.              |
| 10. NAME OF FATHER                                        | Henry D. Bailey                  |
| 11. BIRTHPLACE OF FATHER                                  | Virginia                         |
| 12. MAIDEN NAME OF MOTHER                                 | Martha B. Hart                   |
| 13. BIRTHPLACE OF MOTHER                                  | Virginia                         |
| 14. INFORMANT                                             | Mrs. J. B. Holloway              |
| Address                                                   | Ettrick Va.                      |
| 15. DATE FILED                                            | Dec 27, 1922                     |
| Registrar                                                 | W. H. Larson                     |
| 16. DATE OF DEATH                                         | Dec 25, 1922                     |
| 17. I HEREBY CERTIFY, THAT I ATTENDED DECEASED FROM       | Dec 11, 1922 to Dec 25, 1922     |
| That last saw alive on                                    | Dec 25, 1922                     |
| And that death occurred on the date stated above, at      | 11:15 PM                         |
| The cause of death was as follows                         | Chronic nephritis                |
| (Duration)                                                | 1 1/2 yrs.                       |
| Contributory (secondary)                                  | Uremia                           |
| (Duration)                                                | 5 mos.                           |
| 18. WHERE WAS DISEASE CONTRACTED IF NOT AT PLACE OF DEATH | at place of death                |
| DID AN OPERATION PRECEDE DEATH?                           | No                               |
| WAS THERE AN AUTOPSY?                                     | No                               |
| WHAT TEST CONFIRMED DIAGNOSIS                             | Clinical & Laboratory            |
| Signed                                                    | J T Mooris & Son , Petersburg Va.|
| 19. PLACE OF BURIAL, CREMATION, OR REMOVAL                | Ettrick, Va.                     |
| DATE OF BURIAL, CREMATION, OR REMOVAL                     | Dec 27, 1922                     |
| 20. UNDERTAKER                                            | J. M. Moore & Son                |
| Address                                                   | Petersburg Va.                   |
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