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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hudson
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5316
Primary Registration District No:  
File No.  30829
Registered No:  13
2. FULL NAME:  Wallace Hale Gregory
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  Dec 9, 1913
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 year and 5 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  none
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ky
10. NAME OF FATHER:  Henry Gregory
11. BIRTHPLACE OF FATHER:  Ky
12. MAIDEN NAME OF MOTHER:  Lillie Hardin
13. BIRTHPLACE OF MOTHER:  Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  [unreadable]
(Address)  Hardin Springs, Ky
15. Filed  Dec 16, 1914
REGISTAR:  J. H. Comer
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Dec 14, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  Dec 5  to Dec 14, 1914
That I last saw him/her alive on (date):  Dec 14, 1914
And that death occurred on the date stated above at (time AM/PM):  8:15 PM
THE CAUSE OF DEATH was as follows:  Pneumonia
 
(Duration)   Years:            Months:            Days:  8
Contributory:  Hepatitis
 
(Duration)   Years:            Months:            Days:  6
Signed (M.D.):  J. E. Hale
Date:  Dec 15, 1914
Address:  Hardin Springs, 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:  Legrand Cemetery
DATE OF BURIAL:  Dec 16, 1914
20. UNDERTAKER:  William Burkhead
ADDRESS:  Hardin Springs, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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