************************************************************************ 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.: Stephensport Inc Town: Sample City: No. St. Ward Registration District No.: Primary Registration District No: File No. 255 Registered No: 2 1. FULL NAME: John Roland Bryant PERSONAL AND STATICAL PARTICULARS 2. SEX: male 3. COLOR OR RACE: white 4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single 5. DATE OF BIRTH: Jan 1, 1911 (what is written) 6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 4yrs3mos20ds 7. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 8. BIRTHPLACE: Breckinridge, Ky 9. NAME OF FATHER: Abe Bryant 10. BIRTHPLACE OF FATHER: Breckinridge Ky 11. MAIDEN NAME OF MOTHER: Claudia Role 12. BIRTHPLACE OF MOTHER: Breckinridge Ky 13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Abe Bryant (Address) McQuady Ky 14. Filed Jan 31, 1911 REGISTAR: R.A. Shellman MEDICAL CERTIFICATE OF DEATH 15. DATE OF DEATH: Jan 31, 1911 16. I HEREBY CERTIFY, That I attended deceased from (date): Jan 28, 1911 to Jan 30, 1911 That I last saw him/her alive on (date): Jan 30, 1911 And that death occurred on the date stated above at (time AM/PM): 4:26 AM THE CAUSE OF DEATH was as follows: Diptheria (Duration) Years: Months: Days: 3ds Signed (M.D.): Sm. L. Milner Date: Jan 31, 1911 Address: Union Star, Ky 17. 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: 18. PLACE OF BURIAL OR REMOVAL DATE OF BURIAL: Jan 31, 1911 19. UNDERTAKER: W.J. Schopp ADDRESS: Stephensport, Ky ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************