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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Custer
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5315
Primary Registration District No:  15
File No.  17480
Registered No:  76
2. FULL NAME:  William D. Carman
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widower
6. DATE OF BIRTH:  March 1836
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  78 years
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:  Thomas Carman
11. BIRTHPLACE OF FATHER:  Ky
12. MAIDEN NAME OF MOTHER:  Polly Carman
13. BIRTHPLACE OF MOTHER:  Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. W. Carman
(Address)  Custer, Ky
15. Filed  July 21, 1914
REGISTAR:  J. S. Mitcham
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 21, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  April 1914 to July 1914
That I last saw him/her alive on (date):  July 21, 1914
And that death occurred on the date stated above at (time AM/PM):  3 AM
THE CAUSE OF DEATH was as follows:  Chronic Nephritis
 
(Duration)   Years:            Months:   3         Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. W. Meador
Date:  July 22, 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:  Morris B.G.
DATE OF BURIAL:  July 22, 1914
20. UNDERTAKER:  James M. Pile
ADDRESS:  Custer, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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