************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDTGE Vot. Pol.: 5307 Inc Town: CLOVERPORT City: No. St. Ward: Registration District No.: 131 Primary Registration District No: 2065 File No. 125 Registered No: 2. FULL NAME: ALLEN, JAMES H. PERSONAL AND STATICAL PARTICULARS 3. SEX: MALE 4. COLOR OR RACE: WHITE 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 6. DATE OF BIRTH: JAN 20, 1907 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 6 / 10 / 3 8. OCCUPATION (a.) Trade, profession or particular kind of work: NONE (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: KENTUCKY 10. NAME OF FATHER: WM. B. ALLEN 11. BIRTHPLACE OF FATHER: KENTUKCY 12. MAIDEN NAME OF MOTHER: JENNIE WITT 13. BIRTHPLACE OF MOTHER: KENTUCKY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) JOE ALLEN (Address) CLOVERPORT 15. Filed OCT 25, 1913 REGISTAR: J.C. NOLTE MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: OCT 24, 1913 17. I HEREBY CERTIFY, That I attended deceased from (date): OCT 15, 1913 to OCT 24, 1913 That I last saw him/her alive on (date): OCT 24, 1913 And that death occurred on the date stated above at (time AM/PM): 3:30 PM THE CAUSE OF DEATH was as follows: LOBAR PNEUMONIA (Duration) Years: Months: Days: 9 Contributory: (Duration) Years: Months: Days: Signed (M.D.): E.C. McDANIEL Date: OCT 25, 1913 Address: CLOVERPORT 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: CLOVERPORT DATE OF BURIAL: OCT 25, 1913 20. UNDERTAKER: M. HAMMON & SONS ADDRESS: CLOVERPORT ADDITIONAL COMMENTS/NOTES: ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************