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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.: Hudson, Ky
Inc Town:
City:
No. 5316
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 11579
Registered No: 7
1. FULL NAME: Still Birth
PERSONAL AND STATICAL PARTICULARS
2. SEX: male 
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED:
5. DATE OF BIRTH: May 4, 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?):
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Constantine, Ky
9. NAME OF FATHER: Pascal Drake
10. BIRTHPLACE OF FATHER: Big Springs, Ky
11. MAIDEN NAME OF MOTHER: Lula Drake
12. BIRTHPLACE OF MOTHER: Vertrees, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Lula Drake
(Address) Constantine, Ky
14. Filed 5/10/1911
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: 5-4-1911
16. I HEREBY CERTIFY, That I attended deceased from (date): May 4, 1911 to May 4, 1911
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:
Mother fell  from the top of a 4 ft fence which caused the death
(Duration)
Years:
Months:
Days:
Signed (M.D.): S.J. Hall
Date:
Address:
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: Family Grave Yard
DATE OF BURIAL: 5/4/1911
19. UNDERTAKER: Pascal Drake
ADDRESS: Constantine, Ky



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Copyright.  All rights reserved.
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