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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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1.       PLACE OF DEATH

County:    BRECKINRIDGE

Vot. Pol.:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward  2

Registration District No.:  

Primary Registration District No:  

File No.248   

Registered No:  21

2.       FULL NAME:  ALLEN, JOHN

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  M

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  JUNE 25, 1836

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  74 /6 / 17

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

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  ALLEN, JAMES

11.   BIRTHPLACE OF FATHER:  VA

12.   MAIDEN NAME OF MOTHER:  SULLIVAN, SALLIE

13.   BIRTHPLACE OF MOTHER:  VA

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

(Informant)  JAMES ALLEN

(Address)  HARDINSBURG

15.   Filed  JAN 11, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  JAN 7, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  “DID NOT ATTEND DECEASED.  HE DIED WITHOUT A PHYSICIAN.”

That I last saw him/her alive on (date):  

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

THE CAUSE OF DEATH was as follows:  “FROM WHAT I CAN LEARN HE DIED OF CARDIAC ASTHMA. HE HAD HAD ASTHMA FOR YEARS.

 

(Duration)  

Years:  

Months:  

Days:  

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

Date:  JAN 11, 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  HORSLEY CEMETERY

DATE OF BURIAL:  JAN 8, 1911

20.   UNDERTAKER:  B.F. BEARD & CO.

ADDRESS:  HARDINSBURG

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Copyright.  All rights reserved.
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