Jessie Otis Wallace
Death Certificate

Certificate of Death
Georgia Department of Public Health
State File No.: 94
L. R. File No. 6353
1. Place of Death
a) County Walton Militia Dist No. 419

2.a) State: GA.
(b) County Walton
(c) City of Town: Monroe, GA
State: Ga. County: Walton
City or Town: Monroe, GA

2. Usual Residence of Deceased
a) State: Ga.
(b) County: Walton
c) City or Town: Monroe, GA

3. Full Name: Jessie Otis Wallace
Social Security Number 254-03-0843
4. Sex: Male
5. Race: W
6. Marital Status
7. If married or widowed give name of spouse: Mrs. Florence Wallace

8. Age: Years: 62 Months: 5 Days: 3
9. Date of Birth: 3-9-1880 Birth Place: Clarke Co., GA
10: Usual Occupation: Textile
12. Father Name Thomas Jerome Wallace
13. Birthplace: Georgia Elbert Co.
14. Maiden Name Madeline Lord
15. Birth place: GA

16. Informant's own signature: Tom Wallace
17. Informants P. O. Address: Monroe, GA
18. Burial, Cremation or Removal: West Haven (a) Date 8-14-42
19. P. O. Address of Place of Burial: Monroe, GA
20. Signature of Person Burying Body: E. L. Almand Co.
21. P. O.Address of Undertaker: Monroe, GA Date Filed with L.R.: 9-2-42
22. Registrar's Own Signature: P. A. Dickinson

23. Date of Death: 8-12-42 time: 5:30 pm
24. I hereby certify that I attended the deceased who died on the above date. I last saw him alive on dead on arrival Primary cause of death: coronary heart disease hypertension-arterio sclerosis duration 1 yr 2 mos

26. Physician's Own Signature: Philip R. Stewart M. D.
Physician's P. O. Address: Monroe, GA Date Signed: 9-1-42

Certificate of Record

This is an exact copy of the death certificate, received for filing in

Walton County, Georgia.

Edith M. Weaver By: Lou L. Lowe
Local Custodian of Vital Records Certified Copy Clerk
Walton County Date 11-8-2002

Note: Born in Rockmart Conyers, GA and parents once lived in Clarke Co., GA.

Obtained by Connie Epps Bond on 11-8-2002 from the Walton Co., GA Health Department