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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.: Rockvale

Inc Town: 

City: 

No. 

St. 

Ward

Registration District No.: 132

Primary Registration District No: 5320

File No. 2927

Registered No: 

2.       FULL NAME: James Byers

PERSONAL AND STATICAL PARTICULARS

3.       SEX: 

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: Aug 4, 1870

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 41 yrs 4 mos

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

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

9.       BIRTHPLACE: Grayson Co KY

10.   NAME OF FATHER: James Byres

11.   BIRTHPLACE OF FATHER: Grayson Co KY

12.   MAIDEN NAME OF MOTHER: Elizabeth Allen

13.   BIRTHPLACE OF MOTHER: Grayson Co KY

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

(Informant) H A Blain

(Address) Fordsville KY

15.   Filed Jan 8, 1912

REGISTAR: E L Robertson

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Jan 4, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Nov 30, 1911 to Jan 1, 1912

That I last saw him/her alive on (date): Jan 1, 1912

And that death occurred on the date stated above at (time AM/PM): 8 PM

THE CAUSE OF DEATH was as follows: Carbuncle

 

(Duration)

Years:

Months: 2

Days: 15

Signed (M.D.): W C Hedden

Date: Jan 5th, 1912

Address: Fordsville #2

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  Pleasant Grove

DATE OF BURIAL: 1-5, 1912

20.   UNDERTAKER: T E Butler

ADDRESS: Fordsville Rt 2


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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