************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pct: BALLTOWN #21 Inc Town: City: No. St. Ward: Registration District No.: 5321 Primary Registration District No: File No. 441 Registered No: 2. FULL NAME: APPLEGATE, WILLIAM PERSONAL AND STATISTICAL PARTICULARS 3. SEX: MALE 4. COLOR OR RACE: WHITE 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: 6. DATE OF BIRTH: JAN 28, 1912 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 4 HOURS 8. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: KENTUCKY 10. NAME OF FATHER: PHADUS APPLEGATE 11. BIRTHPLACE OF FATHER: KENTUCKY 12. MAIDEN NAME OF MOTHER: RHODA A. WOOD 13. BIRTHPLACE OF MOTHER: KENTUCKY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) BEN WOOD (Address) MATTINGLY, KY 15. Filed JAN 30, 1912 REGISTAR: FRED FRANK MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: JAN 28, 1912 17. I HEREBY CERTIFY, That I attended deceased from (date): JAN 28, 1912 to JAN 28, 1912 That I last saw him/her alive on (date): JAN 28, 1912 And that death occurred on the date stated above at (time AM/PM): 9 AM THE CAUSE OF DEATH was as follows: UNKNOWN (Duration) Years: Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): ELLA KEENAN, MIDWIFE Date: JAN 28, 1912 Address: MATTINGLY, KY 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: TARFORK DATE OF BURIAL: JAN 29, 1912 20. UNDERTAKER: J.B. JACKSON ADDRESS: MATTINGLY, KY ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************