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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:  Breckenridge

Vot. Pol.:  Custer, Ky

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  53115

Primary Registration District No:  15

File No.  6241

Registered No:  67

2.    FULL NAME:  Silas Bruner

PERSONAL AND STATICAL PARTICULARS

3.    SEX:  male

4.    COLOR OR RACE:  white

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

6.    DATE OF BIRTH:  November 18, 1900

7.    AGE  (yr. mo. da) (If less than 1 day, hours or min?): 13 y,3 m,16 d

8.    OCCUPATION (a.) Trade, profession or particular kind of work:  none

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

9.    BIRTHPLACE:  Kentucky

10.   NAME OF FATHER:  Edd Bruner

11.   BIRTHPLACE OF FATHER: Kentucky 

12.   MAIDEN NAME OF MOTHER:  Laura Gray

13.   BIRTHPLACE OF MOTHER:  Kentucky

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

(Informant)  Willie Pile

(Address)  Custer, Ky

15.   Filed  March 4, 1914

REGISTAR: J. S. Mitcham 

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  March 4, 1914

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Jan, 1910 to March 4, 1914

That I last saw him/her alive on (date):  March 4, 1914

And that death occurred on the date stated above at (time AM/PM):  3 PM

THE CAUSE OF DEATH was as follows:  Dropsy

 

(Duration)   Years:            Months:     2       Days:  

Contributory:  Tuberculosis and Heart, Kidneys

 

(Duration)   Years:    2        Months:   2         Days:  

Signed (M.D.):  R. W. Meador

Date:  March 4, 1914

Address:  Custer, 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:  Tebe Bruner B. G. 

DATE OF BURIAL:  march 5, 1914

20.   UNDERTAKER:  Alex Taylor

ADDRESS:  Custer, Ky

 

 

ADDITIONAL COMMENTS/NOTES:

 

 





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Copyright.  All rights reserved.
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