************************************************************************ 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.: Custer, KY Inc Town: City: No. St. Ward: Registration District No.: Primary Registration District No: 5315 File No. 17199 Registered No: 2. FULL NAME: Davis, Gordon PERSONAL AND STATICAL PARTICULARS 3. SEX: Male 4. COLOR OR RACE: White 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Marrie 6. DATE OF BIRTH: Apr. 13, 1874 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 37 y 3 mo 10 da 8. OCCUPATION (a.) Trade, profession or particular kind of work: Farming (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: KY 10. NAME OF FATHER: George Davis 11. BIRTHPLACE OF FATHER: KY 12. MAIDEN NAME OF MOTHER: Mary Etta Pumphey 13. BIRTHPLACE OF MOTHER: KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) George Davis (Address) Locust Hill, KY 15. Filed July 25, 1911 REGISTAR: R. O. Penick MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: July 23, 1911 17. I HEREBY CERTIFY, That I attended deceased from (date): July 4, 1911 That I last saw him/her alive on (date): July 23, 1911 And that death occurred on the date stated above at (time AM/PM): 7 PM THE CAUSE OF DEATH was as follows: Typhoid fever (Duration) Years: Months: Days: 19 Contributory: General Pertonitis (Duration) Years: Months: Days: Signed (M.D.): John E. Kincheloe Date: July 24, 1911 Address: Hardinsburg, 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: Wm. Davis Cemetery DATE OF BURIAL: July 24, 1911 20. UNDERTAKER: Robert Weatherford ADDRESS: Harned, KY ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************