************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ 1. PLACE OF DEATH County: Breckinridge Vot. Pol.: Breckinridge Inc Town: City: Webster No. 5311 St. Ward Registration District No.: Primary Registration District No: File No. 16782 Registered No: 2. FULL NAME: Died within 1 hr after birth PERSONAL AND STATICAL PARTICULARS 3. SEX: male 4. COLOR OR RACE: white 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: 6. DATE OF BIRTH: Jan 2, 1911 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 60 minutes 8. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Webster, Ky 10. NAME OF FATHER: Robt. Brown 11. BIRTHPLACE OF FATHER: Indiana 12. MAIDEN NAME OF MOTHER: Sarah Doanes 13. BIRTHPLACE OF MOTHER: Indiana 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Robert Brown (Address) Webster, Ky. 15. Filed 1911 REGISTAR: H Doane MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: June 2, 1911 17. I HEREBY CERTIFY, That I attended deceased from (date): June 2, 1911 to June 2, 1911 That I last saw him/her alive on (date): June 2, 1911 And that death occurred on the date stated above at (time AM/PM): 6 AM THE CAUSE OF DEATH was as follows: Premature birth (Duration) Years: Months: Days: Signed (M.D.): S.P. Parks Date: June 2, 1911 Address: Irvington, 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: Webster, Ky. DATE OF BURIAL: June 2, 1911 20. UNDERTAKER: R. A. Kasey ADDRESS: ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************