1.       PLACE OF DEATH

County: Breckinridge

Vot. Pol.: Rockvale

Inc Town:

City:

No.

St.

Ward

Registration District No.: 5320

Primary Registration District No:

File No. 8755

Registered No:

2.       FULL NAME: Robert Awbery

PERSONAL AND STATICAL PARTICULARS

3.       SEX: male

4.       COLOR OR RACE: white

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

6.       DATE OF BIRTH: April 19, 1907

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 4 years, 7 months, 28 days

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

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

9.       BIRTHPLACE: Breck Co.

10.   NAME OF FATHER: Cra_ton Awbery

11.   BIRTHPLACE OF FATHER: Breck Co.

12.   MAIDEN NAME OF MOTHER: Flora Jones

13.   BIRTHPLACE OF MOTHER: Breck Co.

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

(Informant) M.O. Robertson

(Address)

15.   Filed

REGISTAR:

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: 17th of Nov, 1911 [DELAY stamped over date]

17.   I HEREBY CERTIFY, That I attended deceased from (date): on Nov 16, 1911

That I last saw him/her alive on (date): Nov 16, 1911

And that death occurred on the date stated above at (time AM/PM): 1 am

THE CAUSE OF DEATH was as follows: Typhoid Fever

 (Duration)

Years:

Months:

Days: 17

Signed (M.D.): M.O. Robertson

Date: May 17, 1911

Address: Glen Dean, 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 Masedonia

DATE OF BURIAL: Nov 18, 1911

20.   UNDERTAKER:

ADDRESS:

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