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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  GLEN DEAN
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5319
Primary Registration District No:  19
File No.  26367
Registered No:  
2.	FULL NAME:  DAVIS, LEWIS
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  DEC 10, 1910
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  4 / 10 / ILLEG.
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  	HARRY DAVIS
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  POLLY DECKER
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  HARRY DAV\IS
(Address)   GLEN DEAN
15.	Filed  	NOV 12, 1915
REGISTAR:  MRS MOLLY DEMPSTER
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  NOV 11, 1915
17.	I HEREBY CERTIFY, That I attended deceased from (date):  DIED BEFORE I ARRIVED
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  RICKETS
(Duration)   Years:            Months:    1        Days:    4
Contributory:  
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P.E. DEMPSTER
Date:  NOV 11, 1915
Address:  
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:  OWEN GRAVEYARD
DATE OF BURIAL:  NOV 12, 1915
20.	UNDERTAKER:  B.F. BEARD & CO
ADDRESS:  HARDINSBURG


ADDITIONAL COMMENTS/NOTES:




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