************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: UNION STAR Inc Town: City: No. St. Ward: Registration District No.: Primary Registration District No: File No. 12327 Registered No: 2. FULL NAME: BROWN, SON PERSONAL AND STATICAL PARTICULARS 3. SEX: MALE 4. COLOR OR RACE: WHITE 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 6. DATE OF BIRTH: MAY 12, 1914 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 8. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: BRECKINRIDGE 10. NAME OF FATHER: HENRY BROWN 11. BIRTHPLACE OF FATHER: PERRY COUNTY, INDIANA 12. MAIDEN NAME OF MOTHER: MAUDE BROWN 13. BIRTHPLACE OF MOTHER: PERRY COUNTY, INDIANA 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) HENRY BROWN (Address) 15. Filed REGISTAR: MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: MAY 12, 1914 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: STILLBORN (Duration) Years: Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): WILLIAM L. MILNER Date: MAY 12, 1914 Address: UNION STAR 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: DATE OF BURIAL: SHELLMAN GRAVEYARD 20. UNDERTAKER: MAY 13, 1914 ADDRESS: A - - - - - - [DIFFICULT TO READ/SMEARED] ADDITIONAL COMMENTS/NOTES: ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************