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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Rockvale
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5320
Primary Registration District No:  
File No.  33516
Registered No:  
2.	FULL NAME:  Foss Dougherty
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Male
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Yes
6.	DATE OF BIRTH:  1874
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  40 yrs
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  Farmer
9.	BIRTHPLACE:  Butler Co., Ky
10.	NAME OF FATHER:  Don’t know
11.	BIRTHPLACE OF FATHER:  “
12.	MAIDEN NAME OF MOTHER:  “
13.	BIRTHPLACE OF MOTHER:  “
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. C. Willis
(Address)  Rockvale
15.	Filed  2/25, 191
REGISTAR:  J. D. McDonogh
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Feby 25, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
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:  Consumpion of the bowles

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  No attending physician
Date:  
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:  Robinson Grave Yard
DATE OF BURIAL:  2/25, 1914
20.	UNDERTAKER:  
ADDRESS:  


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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