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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.:  12
Inc Town:  Irvington KY
City:  
No.  
St.  
Ward:  
Registration District No.: 5312  [stamped 22682]
Primary Registration District No:  10
File No.  
Registered No:  
2. FULL NAME:  John Board Jr.
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  Black
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single 
6. DATE OF BIRTH:  May 14, 1894
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  17   3  23
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  
10. NAME OF FATHER:  John Board Sr.
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  
13. BIRTHPLACE OF MOTHER:  
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  B. W. Carter
(Address)  Irvington  KY
15. Filed  Sept 6, 1911
REGISTAR:  D. W. Henry
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Sept 6, 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):  
THE CAUSE OF DEATH was as follows:  Eplptic [sic] fit & Drowned in pond

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  
Date:  
Address:  
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:  (Colored Cemetery?) Irvington, KY
DATE OF BURIAL:  Sept 7, 1911
20. UNDERTAKER:  G. T. Marshall & Son
ADDRESS:  Irvington, KY

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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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************************************************