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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Glen Dean
Inc Town:  Glen Dean
City:  
No.  
St.  
Ward:  
Registration District No.:  5319
Primary Registration District No:  19
File No.  17910
Registered No:  
2. FULL NAME:  Samuel H. Harrison
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widowed
6. DATE OF BIRTH:  July 22, 1913 [year appears to be a mistake]
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  70 years, 11 months
8. OCCUPATION (a.) Trade, profession or particular kind of work:  farmer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Marion County, 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)  Maranda Ann Carlile
(Address)  Kirk, Ky
15. Filed  July 22, 1913
REGISTAR:  Mr.s Molly Dempster
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 22, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  July 20 to July 22, 1913
That I last saw him/her alive on (date):  July 22, 1913
And that death occurred on the date stated above at (time AM/PM):  5 PM
THE CAUSE OF DEATH was as follows:  Fracture of left femure and death by shock.
 
(Duration)   Years:            Months:            Days:  25
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  R. T. Dempster
Date:  July 23, 1913
Address:  Glen Dean, 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:  Glen Dean Cemetery
DATE OF BURIAL:  July 23, 1913
20. UNDERTAKER:  H. Wilson & Co.
ADDRESS:  Glen Dean, Ky
 

ADDITIONAL COMMENTS/NOTES: Breckinridge Cemetery Book Volume 1, page 196 shows Samuel H. Harrison, b. 22 Aug 1842; the Husband of F. E. Harrison. Both are buried at Goshen Baptist Church Cemetery, at Glen Dean, Ky.
 
 
 

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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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