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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.:  5306
Inc Town:  Cloverport, KY
City:  2065
No.  131
St.
Ward  2
Registration District No.:  
Primary Registration District No:
File No.  14261
Registered No:  16
2. FULL NAME:  Eubank,  Not named
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:   white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  June 11, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  premature birth
8. OCCUPATION (a.) Trade, profession or particular kind of work:  none
(b.)  General nature of industry business or establishment which employed:  none
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  J. Benton Eubank
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Maud D. Polk
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  R. T. Polk
(Address)  Cloverport, KY
15. Filed  June 12, 1911 
REGISTAR:  J Nolte       ????????????
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  June 11, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 11, 1911 to June 11, 1911
That I last saw him/her alive on (date):  June 11, 1911
And that death occurred on the date stated above at (time AM/PM):  5:00 p.m.
THE CAUSE OF DEATH was as follows:
Premature birth (6 months)
(Duration)
Years:
Months:
Days:
Signed (M.D.):  A. A. Simons, M.D.
Date:  June 12, 1911
Address:  Cloverport, 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  Cloverport, KY
DATE OF BURIAL:  June 12, 1911
20. UNDERTAKER:  M. Hammon & Son    ?????
ADDRESS:   Cloverport, KY

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Copyright.  All rights reserved.
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