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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.:  MOOK

Inc Town:  MOOK

City:  

No.  

St.  

Ward:  

Registration District No.:  VERSAILLES DISTRICT #2

Primary Registration District No:  

File No.  268

Registered No:  2

2.        FULL NAME:  BUTLER, VICTOR

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  MALE

4.        COLOR OR RACE:  WHITE

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

6.        DATE OF BIRTH:  DEC 28, 1910

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  28 DAYS

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

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

9.        BIRTHPLACE:  BRECKINRIDGE

10.     NAME OF FATHER:  WILBER BUTLER

11.     BIRTHPLACE OF FATHER:  KENTUCKY [BURAS SCRATCHED OUT]

12.     MAIDEN NAME OF MOTHER:  DAISY HARRIS

13.     BIRTHPLACE OF MOTHER:  LOCUST HILL, KENTUCKY

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

(Informant)  LONNIE BUTLER

(Address)  LOCUST HILL, KENTUCKY

15.     Filed  JAN 18, 1911

REGISTAR:  W.G. GOODMAN

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  JAN 18, 1911

17.     I HEREBY CERTIFY, That I attended deceased from (date):  

That I last saw him/her alive on (date):  JAN 1, 1911

And that death occurred on the date stated above at (time AM/PM):  7 PM

THE CAUSE OF DEATH was as follows:  PREMATURE BIRTH

 

(Duration)   Years:            Months:            Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

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

Date:  

Address:  CUSTER

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:  TURPIN GRAVEYARD

DATE OF BURIAL:  JAN 18, 1911

20.     UNDERTAKER:  JOHN M. CARMAN

ADDRESS:  LOCUST HILL

 

TRANSCRIBER’S NOTE:  

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