1.       PLACE OF DEATH

County:    BRECKINRIDGE

Vot. Pol.:  ROCKVALE

Inc Town:  

City:  

No.  

St.  

Ward  

Registration District No.:  

Primary Registration District No:  

File No.   5643

Registered No:  

2.       FULL NAME:  ASKINS, HENRY

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  MALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  MAR 19, 1911

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:  INFANT

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

9.       BIRTHPLACE:  ROCKVALE, BRECKINRIDGE, KY

10.   NAME OF FATHER:  ASKINS, ISOM

11.   BIRTHPLACE OF FATHER:  BRECKINRIDGE

12.   MAIDEN NAME OF MOTHER:  CARTER, LILLE

13.   BIRTHPLACE OF MOTHER:  OHIO CO, KY

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

(Informant)  ISOM ASKINS

(Address)  ROCKVALE, KY

15.   Filed   MAR 19, 1911

REGISTAR: G.L.  ROBERTSON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  MARCH 19, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  MARCH 19, 1911 to MARCH 19, 1911

That I last saw him/her alive on (date):  MAR 19, 1911

And that death occurred on the date stated above at (time AM/PM):  7PM

THE CAUSE OF DEATH was as follows:   “THIS CHILD WAS DELIVERED WITH FORCEPS FROM A MOTHER AFFLICTED WITH  PUERPERAL ECLAMPSIA AND DIED IN FOUR HOURS.”

 

(Duration)  

Years:  

Months:  

Days:  

Signed (M.D.):  R.L. DEMPSTER

Date:  

Address:  GLEN DEAN

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  

DATE OF BURIAL:  

20.   UNDERTAKER:  

ADDRESS:  
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