************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************************************
************************************************************************

File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

************************************************************************
1.	PLACE OF DEATH
County: Breckinridge  
Vot. Pol.: 12
Inc Town: Irvington
City:  
No.  5312
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  	26523
Registered No:  
2.	FULL NAME: John Daniel
PERSONAL AND STATICAL PARTICULARS
3.	SEX: Male
4.	COLOR OR RACE: Black
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED: Widower
6.	DATE OF BIRTH: Don’t Know, 1821
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 91 years
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed: Farmer
9.	BIRTHPLACE: KY
10.	NAME OF FATHER: Bill Daniels  
11.	BIRTHPLACE OF FATHER: Virginia
12.	MAIDEN NAME OF MOTHER: Don’t Know
13.	BIRTHPLACE OF MOTHER: Don’t Know
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ******** (unable to read)*****
(Address) Irvington, KY 
15.	Filed  
REGISTAR:  
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  		September 4, 1912
17.	I HEREBY CERTIFY, That I attended deceased from (date): August 23, 1912 to Sept 4, 1912
That I last saw him/her alive on (date): August 28, 1912
And that death occurred on the date stated above at (time AM/PM): 2:00 AM
THE CAUSE OF DEATH was as follows: Paralysis

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.): S P Parks
Date: Sept 4, 1912
Address: Irvington, 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: Irvington, KY 
DATE OF BURIAL: Sept 5, 1912
20.	UNDERTAKER: I B Richardson
ADDRESS: Garfield, KY 

************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************************************