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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Mooleyville
Inc Town: in rural dist
City: near Rhodelia
No.
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 256
Registered No: 5310 
1. FULL NAME: Olliver Dominic Burch
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: May 18th 1884
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 26yrs7mos20ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.)  General nature of industry business or establishment which employed: farm laborer
8. BIRTHPLACE: Breckinridge Co, Ky
9. NAME OF FATHER: Ollie Burch
10. BIRTHPLACE OF FATHER: Mooleyville, Ky
11. MAIDEN NAME OF MOTHER: Sarah Avitt
12. BIRTHPLACE OF MOTHER: Rhodelia, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Dr. T.H. Hardesty
(Address) Payneville, Ky
14. Filed Jan 9, 1911
REGISTAR: J.D. Cunningham
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: January 8th 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Jan 6, 1911 to Jan 8, 1911
That I last saw him/her alive on (date): Jan 8, 1911
And that death occurred on the date stated above at (time AM/PM): 3 PM
THE CAUSE OF DEATH was as follows:
Gun shot wound in thighs & <s----> done by person supposed to be insane
(Duration)
Years:
Months:
Days: 2
Contributory: Hemorhage from femoral artery
Duration: 4 hrs
Signed (M.D.): Dr. T.H. Hardesty
Date: Jan 8th, 1911
Address: Paynesville, 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: Meade Co, Ky
DATE OF BURIAL: Jan 9th 1911
19. UNDERTAKER: J.E. Ball
ADDRESS: Andyville, Ky

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Copyright.  All rights reserved.
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