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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  WEBSTER
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5311
Primary Registration District No:  11
File No.  6041
Registered No:  
2.	FULL NAME:  ADKISSON, SIMON B
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  JUL 12, 1848
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  66 / 8 / 4
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  DENTIST
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE
10.	NAME OF FATHER:  ABNER ADKISSON
11.	BIRTHPLACE OF FATHER:  MADISON COUNTY
12.	MAIDEN NAME OF MOTHER:  NANCY AVITT
13.	BIRTHPLACE OF MOTHER:  BRECKINRIDGE
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) THAD MAYS 
(Address)  WESBSTER
15.	Filed  MAR 17, 1915
REGISTAR:  H. DRANE
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  MAR 16, 1915
17.	I HEREBY CERTIFY, That I attended deceased from (date):  MAR 12, 1915 to MAR 15, 1915
That I last saw him/her alive on (date):  MAR 16, 1915
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  LA GRIPPE
(Duration)   Years:            Months:            Days:    4
Contributory:  
(Duration)   Years:            Months:            Days:  
Signed (M.D.): T.J. HENDRICK 
Date:  MAR 17, 1915
Address:  WEBSTER
18.	LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)
At place of death (yr, mo, da.):  
In the State (yr, mo, da):  
Where was disease contracted,  if not at place of death?  
Former or usual residence:  
19.	PLACE OF BURIAL OR REMOVAL:  WALNUT GROVE
DATE OF BURIAL:  MAR 17, 1915
20.	UNDERTAKER:  G.T. MARSHALL
ADDRESS:  IRVINGTON


ADDITIONAL COMMENTS/NOTES:




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