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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Union Star
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5307
Primary Registration District No:  
File No.  3321
Registered No:  3
2. FULL NAME:  Beauchamp, James W.
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Oct. 16, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  3 mo 29 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., KY
10. NAME OF FATHER:  James P. Beauchamp
11. BIRTHPLACE OF FATHER:  Breckinridge Co., KY
12. MAIDEN NAME OF MOTHER:  Daisy Macy
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  B. H. Beauchamp
(Address)  Mystic, KY
15. Filed  Feb. 16, 1912
REGISTAR:  Lee Stewart
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Feb. 15, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 3, 1912
That I last saw him/her alive on (date):  Feb. 13, 1912
And that death occurred on the date stated above at (time AM/PM):  6 PM
THE CAUSE OF DEATH was as follows:  Eruption skins

(Duration)   Years:            Months:            Days:  All of life
Contributory:  Throat and ears

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  William L. Milner
Date:  Feb. 16, 1912
Address:  Union Star, 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:  Walnut Grove
DATE OF BURIAL:  Feb. 16, 1912
20. UNDERTAKER:  D. S. Richardson
ADDRESS:  Union Star, KY

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Copyright.  All rights reserved.
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