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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  12
Inc Town:  Irvington
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5312
File No.  582
Registered No:  5312
2. FULL NAME:  Burl Grinnell
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  black
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6. DATE OF BIRTH:  Jan 1844
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  69 years
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  [blank]
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  Don't Know
11. BIRTHPLACE OF FATHER:  Don't Know
12. MAIDEN NAME OF MOTHER:  Don't Know
13. BIRTHPLACE OF MOTHER:  Don't Know
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Lige Cleaver
(Address)  Irvington
15. Filed  Jan 18, 1913
REGISTAR:  D. W. Henry
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  January 11, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 10 to Jan 11, 1913
That I last saw him/her alive on (date):  Jan 10, 1913
And that death occurred on the date stated above at (time AM/PM):  12 
THE CAUSE OF DEATH was as follows:  Pneumonia
 
(Duration)   Years:            Months:            Days:  3
Contributory:  Senility
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  S. P. Parks
Date:  Jan 12, 1913
Address:  Irvington, 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:  Irvington
DATE OF BURIAL:  Jan 12, 1913
20. UNDERTAKER:  G. T. Marshall & Son
ADDRESS:  Irvington
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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