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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. Pol.:  GLEN DEAN, KY
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:   5319
Primary Registration District No: 19
File No.  26167
Registered No:   
2. FULL NAME:  THOMAS J EARLY
PERSONAL AND STATICAL PARTICULARS
3. SEX:   MALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  SEPT 27, 1913
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):    18 DA.
8. OCCUPATION (a.) Trade, profession or particular kind of work:    
(b.)  General nature of industry business or establishment which employed:   
9. BIRTHPLACE: GLEN DEAN  KY
10. NAME OF FATHER:  THOMAS EARLY
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  CORA KIPER
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  THOMAS EARLY
(Address)  GLEN DEAN KY
15. Filed  OCT 16, 1913
REGISTAR:  MRS. MOLLY DEMPSTER
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  OCT 15, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  OCT 10, 1913 TO OCT 14, 1913     
That I last saw him/her alive on (date):  ALIVE OCT 14, 1913
And that death occurred on the date stated above at (time AM/PM):  8 PM
THE CAUSE OF DEATH was as follows:   
 
(Duration)   Years:            Months:            Days:  18 
Contributory:  
 
(Duration)   Years:            Months:            Days:   
Signed (M.D.):  PE DEMSTER
Date:   OCT 16, 1913
Address:  GLEN DEAN  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:   GLEN DEAN CEMETARY
DATE OF BURIAL:  OCT 16, 1913
20. UNDERTAKER:  H WILSON & CO
ADDRESS:  GLEN DEAN KY
 

ADDITIONAL COMMENTS/NOTES: UNSURE OF CAUSE OF DEATH

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Copyright.  All rights reserved.
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