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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. Pct:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward:  3

Registration District No.:  130

Primary Registration District No:  5303

File No.  16539

Registered No: 188

2.       FULL NAME:  DOWELL, SAM

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     MALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH: APR 25, 1887

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  25 / 2 / 19

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

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  MARTIN DOWELL

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  PALINA ELIZABETH DOWELL

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  BASIL DOWELL

(Address)  HARDINSBURG

15.   Filed  JUL 13, 1912

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  JUL 12, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  JUL 10, 1912 to JUL 11, 1912

That I last saw him/her alive on (date):  JUL 11, 1912

And that death occurred on the date stated above at (time AM/PM):  5 PM

THE CAUSE OF DEATH was as follows:  APPENDECITIS

 

(Duration)   Years:            Months:            Days:  

Contributory:  GENERAL PERITONITIS

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  JNO E. KINCHELOR

Date:  JUL 12, 1912

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:  HORSLEY CEM

DATE OF BURIAL:  JUL 13, 1912

20.   UNDERTAKER:  B.A. BEARD

ADDRESS:  HARDINSBURG

 



 

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Copyright.  All rights reserved.
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