1. DECEASED-NAME Lola Ethel Peters
2. DATE OF DEATH (MONTH, DAY, YEAR)
1-7-66
3. COLOR OR RACE W
4. SEX F
5. SINGLE, MARRIED, WIDOWED, DIVORCED (SPECIFY)
Married
6. DATE OF BIRTH MONTH DAY YEAR 5-29-1900
7. AGE (IN YEARS LAST BIRTHDAY) 65
8. PLACE OF DEATH A. COUNTY
Knox B. CIVIL DISTRICT 7 C. CITY OR TOWN Knoxville
D. LENGTH OF STAY IN THIS PLACE E. NAME OF HOSPITAL OR INSTITUTION
at St. Mary's Hospital F. INSIDE CITY LIMITS? yes
9. USUAL RESIDENCE OF DECEASED A.
STATE Tennessee B. COUNTY Knox C. CIVIL DISTRICT
8 D. CITY OR TOWN Corryton E. INSIDE CITY LIMITS?
no F. STREET ADDRESS Tazewell Pike, Corryton G. IS RESIDENCE
ON A FARM? no
10. USUSAL OCCUPATION (Kind of Work Done
During Most of Working Life, Even if Retired) Cafeteria 10.B
KIND OF BUSINESS OR INDUSTRY Knox County Schools
11. SOCIAL SECURITY NUMBER
12. WAS DECEASED EVER IN U.S. ARMED FORCES?
No
13. BIRTHPLACE (State or Foreign Country)
Tennessee
14. CITIZEN OF WHAT COUNTRY? U.S.A.
15. NAME OF HUSBAND OR WIFE Ernest Lester
Peters
16. FATHER'S NAME John W. Williamson
17. MOTHER'S NAME Mahala Bray
18. INFORMANT Husband ADDRESS
Same
19. CAUSE OF DEATH PART I DEATH
WAS CAUSED BY: IMMEDIATE CAUSE (1A) Severe Hypertensive Arterioslerotic
cardio-vascular disease. INTERVAL BETWEEN ONSET AND DEATH a
few years PART II OTHER SIGNIFICANT CONDITIONS CONTRIBUTING
TO THE DEATH BUT NOT RELATED TO TERMINAL DISEASE CONDITION GIVEN IN PART
I.
20. WAS AUTOPSY PERFORMED? no
21A. ACCIDENT SUICIDE HOMICIDE (left blank)
21B. DESCRIBE HOW INJURY OCCURRED (left blank) 21.C. TIME OF
INJURY (left blank)
22. SIGNATURE C.E. Irwin M.D. ADDRESS
505 Medical Arts Bldg. Knoxville, Tenn., 37902 DATE 19
Jan 1966
22A. BURIAL, CREMATION, REMOVAL, SPECIFY
Burial 23B. DATE OF BURIAL, CREMATION, OR REMOVAL 1-9-66
23C. NAME OF CEMETERY OR CREMATORY Greenwood Cem. 23D.
LOCATION CITY TOWN OR COUNTY STATE Knoxville, Tenn.
24. FUNERAL DIRECTOR ADDRESS Stevens Mortuary
Knoxville
25. REGISTRATION DIST. NO. 24701
26. DATE SIGNED BY LOCAL REG. Jan.
20, 1966
27. REGISTRAR'S SIGNATURE Mary Chambers