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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. 1

Ward

Registration District No.: 130

Primary Registration District No: 5301

File No. 244

Registered No: 4

2.       FULL NAME: [name is crossed out Stillbirth written in]

PERSONAL AND STATICAL PARTICULARS

3.       SEX: male

4.       COLOR OR RACE: white

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

6.       DATE OF BIRTH: 1/15, 1911

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):0 years,0 mo, 0 days; 0-0-0

8.       OCCUPATION (a.) Trade, profession or particular kind of work: none

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

9.       BIRTHPLACE: Breckinridge County, KY

10.   NAME OF FATHER: Herbert Ball

11.   BIRTHPLACE OF FATHER: KY

12.   MAIDEN NAME OF MOTHER: Maude Milles

13.   BIRTHPLACE OF MOTHER: KY

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

(Informant) Herbert Ball

(Address) Hardinsburg, KY

15.   Filed Jan 15, 1911

REGISTAR: W. B. Lennon

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: 1/15, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):

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

And that death occurred on the date stated above at (time AM/PM): 3 am

THE CAUSE OF DEATH was as follows: Breach Presentation, Pressure on Cord

 [Stillbirth Stamped over the cause of death]

(Duration)

Years:

Months:

Days:

Signed (M.D.): Jno E. Kincheloe

Date: Jan 15, 1911

Address: Hardinsburg, 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

DATE OF BURIAL:

20.   UNDERTAKER:

ADDRESS:

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Copyright.  All rights reserved.
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