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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.:  Union Star

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  #5309

Primary Registration District No:  

File No.  21640

Registered No:  12

2.       FULL NAME:  Dash C Avitt

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  male

4.       COLOR OR RACE:  white

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

6.       DATE OF BIRTH:  February 4, 1862

7.       AGE (yr. mo. da) (If less than 1 day, hours or min?):  50 years, 7 months, 17 days

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

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

9.       BIRTHPLACE:  Breckinridge Co., KY

10.   NAME OF FATHER:  Wm. Avitt

11.   BIRTHPLACE OF FATHER:  Breckinridge Co., KY

12.   MAIDEN NAME OF MOTHER:  Sallie R. Jordan

13.   BIRTHPLACE OF MOTHER:  Breckinridge Co., KY

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

(Informant)  J.R. Burton

(Address)  Mystic, KY

15.   Filed:  9/21, 1912

REGISTAR:  Lee Stewart

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  Sept 21, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  July 1910 to June 1912

That I last saw him/her alive on (date):  July 17, 1912

And that death occurred on the date stated above at (time AM/PM):  5:30 a.m.

THE CAUSE OF DEATH was as follows:  Brights Disease

 

(Duration)   Years:       2     Months:    4        Days:  4

Contributory:  Dropsy

 

(Duration)   Years:            Months:  2          Days:  

Signed (M.D.):  Wm L. Milner

Date:  9/21. 1912

Address:  Union Star

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:  Walnut Grove [unreadable]

DATE OF BURIAL:  9/22, 1912

20.   UNDERTAKER:  W.J. Schopp

ADDRESS:  Stephensport, KY

 


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
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