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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.: Union Star

Inc Town:

City:

No.

St.

Ward

Registration District No.: 5309

Primary Registration District No:

File No. 19023

Registered No: 11

2.       FULL NAME: John Brown

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: 3-27, 1847

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 75 yrs 5 mos 2 da

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

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

9.       BIRTHPLACE: Perry Co IN

10.   NAME OF FATHER: John Brown

11.   BIRTHPLACE OF FATHER: Mead Co KY

12.   MAIDEN NAME OF MOTHER: Maregza Riddle

13.   BIRTHPLACE OF MOTHER: Perry Co IN

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

(Informant) Clyde Brown

(Address)  (Unreadable)

15.   Filed 8/31, 1912

REGISTAR: Lee Stewart

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Aug 29, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Aug 27 1912 to Aug 27, 1912

That I last saw him/her alive on (date): Aug 27, 1912

And that death occurred on the date stated above at (time AM/PM): 1 AM

THE CAUSE OF DEATH was as follows: Flux

 

(Duration)

Years:

Months:

Days: 4

Signed (M.D.): Wm L Milner

Date: Aug 29, 1912

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 (Unreadable)

DATE OF BURIAL: 8-30, 1912

20.   UNDERTAKER: W J Schopp

ADDRESS: Stephensport


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