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1.        PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward:  1st

Registration District No.:  130

Primary Registration District No:  5301

File No.  27330

Registered No: 61 

2.        FULL NAME:  DOWELL, FELIX

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  MALE

4.        COLOR OR RACE:  WHITE

5.        SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE

6.        DATE OF BIRTH:  JUL 25, 1824

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  81 / 4 / -

8.        OCCUPATION (a.) Trade, profession or particular kind of work:  FARMINGTON

(b.)  General nature of industry business or establishment which employed:  

9.        BIRTHPLACE:  KENTUKCY

10.     NAME OF FATHER:  NEHEMIAH DOWELL

11.     BIRTHPLACE OF FATHER:  VIRGINIA

12.     MAIDEN NAME OF MOTHER:  JESSIE DOWELL [DON’T KNOW MAIDEN NAME]

13.     BIRTHPLACE OF MOTHER:  VIRGINIA

14.     THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  - - - - - -  -  DOWELL

(Address)  HARDINSBURG

15.     Filed  NOV 23, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH: NOV 22, 1911 

17.     I HEREBY CERTIFY, That I attended deceased from (date):  AUG 1911 to SEP 1911

That I last saw him/her alive on (date):  NOV 20, 1911

And that death occurred on the date stated above at (time AM/PM):  1 PM

THE CAUSE OF DEATH was as follows:  ORGANIC HEART DISEASE -  ORIGINATION [?]  OF DISEASE NOT KNOWN

 

(Duration)   Years:            Months:            Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  A.M. KINCHLOE

Date:  NOV 22, 1911

Address:  HARDINSBURG

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:  SAMPLE CEMETERY

DATE OF BURIAL:  NOV 23, 1911

20.     UNDERTAKER:  J.T. HOBEN

ADDRESS:  HARDINSBURG


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