************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ 1. PLACE OF DEATH County: Breckinridge Vot. Pol.: Stephensport Inc Town: City: No. St. Ward: Registration District No.: 5308 Primary Registration District No: File No. 25209 Registered No: 61 2. FULL NAME: James Cox PERSONAL AND STATICAL PARTICULARS 3. SEX: Male 4. COLOR OR RACE: White 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single 6. DATE OF BIRTH: Aug. 20, 1914 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 2 mos 3 ds 8. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Breckinridge Co., Ky 10. NAME OF FATHER: S. D. Cox 11. BIRTHPLACE OF FATHER: Breckinridge, Ky 12. MAIDEN NAME OF MOTHER: Dasie Adkison 13. BIRTHPLACE OF MOTHER: Breckinridge Co., Ky 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) S. D. Cox (Address) Sample 15. Filed Nov. 11, 1914 REGISTAR: R. A. Shellman MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: Oct. 22, 1914 17. I HEREBY CERTIFY, That I attended deceased from (date): Oct. 19, 1914 to Oct. 19, 1914 That I last saw him/her alive on (date): Oct. 19, 1914 And that death occurred on the date stated above at (time AM/PM): 10 p.m. THE CAUSE OF DEATH was as follows: Enteritis (Duration) Years: Months: Days: 19 Contributory: (Duration) Years: Months: Days: Signed (M.D.): Wm. l. Milner, M.D. Date: 10/23/1914 Address: Union Star 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: DATE OF BURIAL: 20. UNDERTAKER: ADDRESS: ADDITIONAL COMMENTS/NOTES: ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************