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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.: Custer

Inc Town:

City:

No.

St.

Ward

Registration District No.: 33

Primary Registration District No:

File No. 21643

Registered No:

2.       FULL NAME: Dan Brown

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male    

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: Sept 6, 1837

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 75 yrs 11 da

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

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

9.       BIRTHPLACE: Brandenburg KY Mead County

10.   NAME OF FATHER: Mr. Brown

11.   BIRTHPLACE OF FATHER: Mead County KY

12.   MAIDEN NAME OF MOTHER: Survena Woolridge

13.   BIRTHPLACE OF MOTHER: Mead County, KY

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

(Informant) Dan Halfrries

(Address) Garfield KY

15.   Filed Sept 20, 1912

REGISTAR: R.O. Pennick

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Sept 17, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Sept 14, 1912 to Sep 17, 1912

That I last saw him/her alive on (date): Sept 15, 1912

And that death occurred on the date stated above at (time AM/PM): 9 AM

THE CAUSE OF DEATH was as follows: (Sinility) as digectly  Acute Indigestion

 

(Duration)

Years:

Months:

Days: 5

Contributory: Arterio Scliosis

(Duration)

Years: 10

Months:

Days: 

Signed (M.D.): J.A. Sandbach 

Date: Sept 17, 1912

Address: Garfield, 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 Turpin Cemetery

DATE OF BURIAL: Sept 18, 1912

20.   UNDERTAKER: I.B. Richardson

ADDRESS: Garfield KY





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Copyright.  All rights reserved.
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