1.       PLACE OF DEATH

County:    BRECKINRIDGE

Vot. Pol.:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward  3

Registration District No.:  

Primary Registration District No:  

File No.   22674

Registered No: 57 

2.       FULL NAME:  ALLEN, HENRY

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  MALE

4.       COLOR OR RACE:  BLACK

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED

6.       DATE OF BIRTH:  OCT 15, 1857

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  53 / 11 / 8

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  

(b.)  General nature of industry business or establishment which employed:  FARMING

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  ALLEN, ALLEN

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  PEYTON, ELIZA

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE  

(Informant)  ALLEN, AMELIA

(Address)  HARDINSBURG

15.   Filed  SEPT 23, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  SEPT 23, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  MAY 1, 1911 to SEP 23, 1911

That I last saw him/her alive on (date):  SEPT 20, 1911

And that death occurred on the date stated above at (time AM/PM):  5 AM

THE CAUSE OF DEATH was as follows:  PULMONARY TUBERCULOSIS

 

(Duration)  

Years:  

Months:  

Days:  

Signed (M.D.):  JOHN E. KINCHELOR

Date:  SEPT 23, 1911

Address:  HARDINSBURG

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  HARDINSBURG CEMETERY

DATE OF BURIAL:  SEPT 24, 1911

20.   UNDERTAKER:  J.T. HOBEN 

ADDRESS:  HARDINSBURG

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