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1.	PLACE OF DEATH
County: BRECKINRIDGE 
Vot. Pol.: WEBSTER KY 
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No: 5311 
File No. 31015 
Registered No:  
2.	FULL NAME: HUBERT W. COOMES 
PERSONAL AND STATICAL PARTICULARS
3.	SEX: MALE 
4.	COLOR OR RACE: WHITE 
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  
6.	DATE OF BIRTH: OCT 14, 1912 
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 1YR 21DS 
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE: RAYMOND 
10.	NAME OF FATHER: ORVAL COOMES 
11.	BIRTHPLACE OF FATHER: RAYMOND, KY 
12.	MAIDEN NAME OF MOTHER: EFFIE NORTON 
13.	BIRTHPLACE OF MOTHER: RAYMOND, KY 
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ORVAL COOMES 
(Address)  RAYMOND, KY
15.	Filed 11/5/1913 
REGISTAR: H DRANE 
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: 11-5-1913 
17.	I HEREBY CERTIFY, That I attended deceased from (date): 10/20/1913 TO 11/5/1913 
That I last saw him alive on (date): 11/5/1913 
And that death occurred on the date stated above at (time AM/PM): 10 AM 
THE CAUSE OF DEATH was as follows:  
CHOLERA INFANTUM
(Duration)   Years:            Months: 1          Days: 5 
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  T.J. HENDRICK
Date:  11/5/1913
Address:  WEBSTER, 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: RAYMOND, KY  
DATE OF BURIAL: 11/6/1913 
20.	UNDERTAKER: G.T. MARSHALL & SON 
ADDRESS: IRVINGTON, KY 


ADDITIONAL COMMENTS/NOTES:




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