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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.: Hardinsburg

Inc Town: 

City:

No.

St.

Ward 1

Registration District No.: 130

Primary Registration District No: 5301

File No. 6167

Registered No: 86

2.       FULL NAME: Harrison C Hampton

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male    

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single

6.       DATE OF BIRTH: June 6, 1890

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 21 yrs 8 mos 12 da

8.       OCCUPATION (a.) Trade, profession or particular kind of work: Farming

(b.)  General nature of industry business or establishment which employed:

9.       BIRTHPLACE: Kentucky

10.   NAME OF FATHER: John H Hampton

11.   BIRTHPLACE OF FATHER: Kentucky

12.   MAIDEN NAME OF MOTHER: Martha A Stelenees

13.   BIRTHPLACE OF MOTHER: Kentucky

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant) Francis Hampton

(Address) Kirk KY

15.   Filed Mar 14, 1912

REGISTAR: H B Lennon

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Mar 13, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): (unreadable)

That I last saw him/her alive on (date):

And that death occurred on the date stated above at (time AM/PM): 4 AM

THE CAUSE OF DEATH was as follows: Pulminary Tuburculosis

 

(Duration)

Years: 3

Months:

Days:

Signed (M.D.) J E Kincheloe

Date: Mar 1912

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 Our house cemetery

DATE OF BURIAL: Mar 14, 1912

20.   UNDERTAKER: Pete Sheeran Bro & Co

ADDRESS: Kirk KY




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Copyright.  All rights reserved.
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