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

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1.	PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hardinsburg
Inc Town: Hardingburg
City:  
No.  
St.  
Ward:  		3
Registration District No.:  			130
Primary Registration District No: 5303-3131
File No.  			6173
Registered No: 84
2.	FULL NAME: R M Davis
PERSONAL AND STATICAL PARTICULARS
3.	SEX: Male
4.	COLOR OR RACE: White  
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED: Widowed
6.	DATE OF BIRTH: November 23, 1835
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 76 yrs, 3 mos, 13 days
8.	OCCUPATION (a.) Trade, profession or particular kind of work: Wood Mec
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  			Kentucky
10.	NAME OF FATHER: WM Davis
11.	BIRTHPLACE OF FATHER: Kentucky
12.	MAIDEN NAME OF MOTHER: L Anne Collins 
13.	BIRTHPLACE OF MOTHER: Kentucky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  				R O Davis
(Address)  				Hardinsburg, KY 
15.	Filed  				March 7, 1912
REGISTAR:  				W B Lennon
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  		March 7, 1912
17.	I HEREBY CERTIFY, That I attended deceased from (date): March 4, 1912 to March 7, 1912
That I last saw him/her alive on (date):  	March 6, 1912
And that death occurred on the date stated above at (time AM/PM): 4:20 AM
THE CAUSE OF DEATH was as follows: Pneumonia Labor

(Duration)   Years:            Months:            Days: 3
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  	Jno E Kincheloe
Date: March 7, 1912
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: E Cemetary
DATE OF BURIAL: March 8, 1912
20.	UNDERTAKER: B F  Beard & Co 
ADDRESS:  		Hardinsburg, KY 

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Copyright.  All rights reserved.
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