Document QMvMXQJwrE7VQj5R9eYMdRB7v

PROOF OF DEATH STATEMENT OF EMPLOYER To tub Metropolitan Life Insurance Company: Claim Division. 66S3 GIB Group Number............. Serial Number. .356 Date of Certificate _ City.NorthCharieston^S.C 7/3/33............. ..Amount of Insurance S.50.0^.00 This is to certify that...... BOh..OsTYiS................................... aged....57 died on the.A.7--.day of (Name of Employee) and was in the employ of the undersigned at the date of death. .......19?.^ That the deceased had been so employed from. .9/5/82............ . ..........to...............................................................10. And last reported for work on___ 11/.7/..................... .........192.... Name of Beneficiary....... Ida R. Gary! 8 .................................. Relationship............ Ki.?............. ............. Age......... City or Residence: No. and Street.....1.5.2 .Spring. St .......................Town______ Chari ston ........... State...... S.C. Was deceased cared for by the Company's Nursing Service during last illness?.................... ,. ' GENERAL. ASBESTOS Sc RUBBEK DIYISION Employer ..or. Raybestos-Manna t tan , Inc. Dated... April 2nd.................... 19&4 By W. K. Muckenfuss ..... Send Claim Check ....... ............... tidm......... ............................................................................................. ATTENDING PHYSICIAN'S STATEMENT As the Company preserves a record of its mortality experience, the report of the Attending Physician will be of great service if precise and full answers are given to the following questions. Noth.--If no attending physician, or in case of sudden death by accident or otherwise, attach certified copy of the record of death as shown by the books of the Health Department, Registrar. County Clerk or other officer having charge of such records. 1. Full Name of Deceased? Ben Garvis 2. Date of Death? White or Colored ? White 5. How long had deceased been ill when you were called to attend in last illness ? Since November, 1933 Month . Day 17th.....Year..l934 6. Date of your first visit in last illness ? 3. Place of Death? If death occurred in a hospital or in January 10, 1934 stitution. give its name. 7. Date of your last visit ? No Hop..r..HOBp .Street............................................... . City or Town._...P.^1* *'l^ 4. Cause of Death? .State 3. C*__ Carcinoma, Bronchial Asbestosis ........... From Tan.10, 1934.................. Duration from personal^know^d^e,,..Yrs.....Mos.....Days Duration from history given............. Yrs.....Mos.....Days Contributory or Seoondary Bronohial Secondary ..... Infection........... ........ Don * t knqPuration).......... .Yrs__ Mos..... Days Karoh 17, 1954 8. Was death caused by any condition arising from decedent's occupation? Probably asbestos dust was a contributing factor. 9. Was death due to suicide, homicide or accident? If accident, give particulars and date. No I Hereby Certify that I attended the Deceased from.. ..Jan.lO, 1934...... . t0.... l-Oh. 1.7, 1934..... 192....; that I signed the Certificate on file at the office of the Board of Health or Register of Vital Statistics, and that the answers as above recorded are complete and true to the best of my knowledge and belief. Dated. Signature of Physician........... Aprll 6................... 1934 Residence: No. and Street.... 72 So0i 6ty St ......City or Town ChariestE state. 9S.*. .?..