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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.: Mooleyville

Inc Town: 

City:

No. 10

St.

Ward

Registration District No.:

Primary Registration District No: 5310

File No. 30574

Registered No: 5310

2.       FULL NAME: J. M. Ball

PERSONAL AND STATICAL PARTICULARS

3.       SEX: male

4.       COLOR OR RACE: white

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

6.       DATE OF BIRTH: 

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 79 years, 4 mo, 29 days

8.       OCCUPATION (a.) Trade, profession or particular kind of work: farmer retired 15 years

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

9.       BIRTHPLACE: Ohio

10.   NAME OF FATHER: Wesley Ball

11.   BIRTHPLACE OF FATHER: Do not know

12.   MAIDEN NAME OF MOTHER: Lydia Mitchell

13.   BIRTHPLACE OF MOTHER: Do not know

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

(Informant) G. E. Ball

(Address) Mooleyville, KY

15.   Filed Dec 2, 1911

REGISTAR: J. D. Cunningham [written at bottom: Per Jennie Cunningham]

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Dec 1, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date): Nov 27, 1911 to Nov 30, 1911

That I last saw him/her alive on (date): Nov 30, 1911

And that death occurred on the date stated above at (time AM/PM): 8 am

THE CAUSE OF DEATH was as follows: Cerebral Hemorrhage

 (Duration)

Years:

Months:

Days: 3

Contributory: Chronic Rheumatism; Duration : 20 years

Signed (M.D.): D. Spire

Date: Dec 1, 1911

Address: Mooleyville, 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 Derby, Ind

DATE OF BURIAL: Dec ?, 1911

20.   UNDERTAKER: J. E. Ball

ADDRESS:Andyville, KY

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Copyright.  All rights reserved.
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