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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  McDaniels
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5318
Primary Registration District No:  
File No.  16556
Registered No:  
2. FULL NAME:  Critchlow, Charlie
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  Jan. 16, 1886
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  26 yr 6 mo 21 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., KY
10. NAME OF FATHER:  Huston B. Critchlow
11. BIRTHPLACE OF FATHER:  Breckinridge Co., KY
12. MAIDEN NAME OF MOTHER:  Sallie Kennedy
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Lonnie Critchlow
(Address)  Roff, KY
15. Filed  July 27, 1912
REGISTRAR:  M. M. Jarboe
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: July 27, 1912 
17. I HEREBY CERTIFY, That I attended deceased from (date):  Sept. 1911
That I last saw him/her alive on (date):  July 26, 1912
And that death occurred on the date stated above at (time AM/PM):  2 AM
THE CAUSE OF DEATH was as follows:  Pulmonary tuberculosis following typhoid last summer

(Duration)   Years:   about 1         Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. B. Lampton
Date:  July 27, 1912
Address:  McDaniels, 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:  
DATE OF BURIAL:  
20. UNDERTAKER:  
ADDRESS:  


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