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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.:  Stephensport
Inc Town:  
City:  
No.  
St.  
Ward  1
Registration District No.:  5308
Primary Registration District No:  
File No.  22677
Registered No:  12
2. FULL NAME:  Joe Furrow
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  Mar. 26, 1883
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  28 yrs  5 mos  29 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farm Laborer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Minor Furrow
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Mary Basham
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Luther Dowell
(Address)  Sample, Ky
15. Filed  Sept 28, 1911
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Sept. 25, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jan 1, 1911 to Sept 25, 1911
That I last saw him/her alive on (date):  Aug 2, 1911
And that death occurred on the date stated above at (time AM/PM):  11 p.m.
THE CAUSE OF DEATH was as follows:  Pulmonary Tuberculosis

(Duration)   Years:   2         Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Jno E. Kincheloe
Date:  Sept 27, 1911
Address:  Hardinsburg, 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:  Sample Cemetery
DATE OF BURIAL:  Sept 26, 1911
20. UNDERTAKER:  B. F. Beard & Co.
ADDRESS:  Hardinsburg, Ky

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Copyright.  All rights reserved.
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