************************************************************************ 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. Pct: ROCKVILLE Inc Town: City: No. St. Ward: Registration District No.: Primary Registration District No: File No. 22328 Registered No: 1. FULL NAME: DEHAVEN, JACOB PERSONAL AND STATISTICAL PARTICULARS 2. SEX: MALE 3. COLOR OR RACE: WHITE 4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: MARRIED 5. DATE OF BIRTH: AUG 15, 1845 6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 7. OCCUPATION (a.) Trade, profession or particular kind of work: FARMER (b.) General nature of industry business or establishment which employed: 8. BIRTHPLACE: BRECKINRIDGE 9. NAME OF FATHER: EDWARD DEHAVEN 10. BIRTHPLACE OF FATHER: BRECKINRIDGE 11. MAIDEN NAME OF MOTHER: DOSIA HALL 12. BIRTHPLACE OF MOTHER: OHIO COUNTY 13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) SANDFORD DEHAVEN (Address) FORDSVILLE 14. Filed JUN 27, 1911 REGISTAR: E.L. ROBERTSON MEDICAL CERTIFICATE OF DEATH 15. DATE OF DEATH: JUN 27, 1911 [DELAYED] 16. I HEREBY CERTIFY, That I attended deceased from (date): JUN 18, 1911 to JUN 27, 1911 That I last saw him/her alive on (date): JUN 27, 1911 And that death occurred on the date stated above at (time AM/PM): 11:30 PM THE CAUSE OF DEATH was as follows: GASTRO DUODENITIS (Duration) Years: Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): U.S. HEDDON Date: JUN 28, 1911 Address: FORDSVILLE 17. 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: 18. PLACE OF BURIAL OR REMOVAL: MACEDONIA CEM DATE OF BURIAL: JUN 28, 1911 19. UNDERTAKER: ADDRESS: ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************