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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  12
Inc Town:  Irvington
City:  
No.  
St.  
Ward:  
Registration District No.:  5312
Primary Registration District No:  
File No.  7 [written in by hand] 3 [seems to be written over the 1] 10825
Registered No:  5312
2. FULL NAME:  Edward Everatt Hale
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  child
6. DATE OF BIRTH:  June 4, 1914
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  6 months, 1 day
8. OCCUPATION (a.) Trade, profession or particular kind of work:  child
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckenridge Co., Ky
10. NAME OF FATHER:  Wm. T. Hale
11. BIRTHPLACE OF FATHER:  Hancock Co., Ky
12. MAIDEN NAME OF MOTHER:  L. Musgrove
13. BIRTHPLACE OF MOTHER:  Cope, Ind.
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Moser T. Hale
(Address)  Irvington, Ky
15. Filed  Dec. 6, 1914
REGISTAR:  Sue C. Jolly
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Dec. 5, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  Nov. 26 to Dec. 5, 1914
That I last saw him/her alive on (date):  Dec. 5, 1914
And that death occurred on the date stated above at (time AM/PM):  3 PM
THE CAUSE OF DEATH was as follows:  Pneumonia
 
(Duration)   Years:            Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. A. Lex
Date:  12/5, 1914
Address:  [unreadable]
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:  Blackford
DATE OF BURIAL:  
20. UNDERTAKER:  G. T. Marshall & Son
ADDRESS:  Irvington, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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