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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  130
Inc Town:  5301
City:  
No.  
St.  
Ward:  2nd
Registration District No.:  130
Primary Registration District No:  5308
File No.  8808
Registered No:  18
2. FULL NAME:  DeJARNETTE, RAYMOND
PERSONAL AND STATICAL PARTICULARS
3. SEX:  MALE
4. COLOR OR RACE:  BLACK
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  JAN 6, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  
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:  R. DeJARNETTE
11. BIRTHPLACE OF FATHER:  KENTUCKY
12. MAIDEN NAME OF MOTHER:  MARY C. WOODS
13. BIRTHPLACE OF MOTHER:  KENTUCKY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  ROBT DeJARNETTE
(Address)  -illegible-
15. Filed  APR 5, 1911
REGISTAR:  W.B. LENNON
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: APR 4, 1911 
17. I HEREBY CERTIFY, That I attended deceased from (date):  APR 4, 1911 to APR 4, 1911
That I last saw him/her alive on (date):  APR 4, 1911
And that death occurred on the date stated above at (time AM/PM):  1:45 AM
THE CAUSE OF DEATH was as follows:  PNEUMONIA IN BOTH LUNGS

(Duration)   Years:            Months:            Days:  2
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J.D. MATTHEWS
Date:  APR 4, 1911
Address:  WESTVIEW, 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:  NEAR GARFIELD
DATE OF BURIAL:  APR 5, 1911
20. UNDERTAKER:  P. SHEERAN BRO & CO
ADDRESS:  KIRK, KY


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