1.       PLACE OF DEATH

County: Breckinridge

Vot. Pol.: Glen Dean

Inc Town:

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 22688

Registered No:

2.       FULL NAME: John Loid Hazelwood

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: December 1874

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 37 yrs 1 mos 4 da

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

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

9.       BIRTHPLACE: Grayson Co KY

10.   NAME OF FATHER: Joshua Hazelwood

11.   BIRTHPLACE OF FATHER: Marion Co KY

12.   MAIDEN NAME OF MOTHER: Mary Raily

13.   BIRTHPLACE OF MOTHER: Marion Co KY

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

(Informant) 

(Address) J H Hazelwood

15.   Filed Sept 20, 1911

REGISTAR: E.L. Robertson

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Sept 20, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date): Sept 16, 1911 to Sept 20, 1911

That I last saw him/her alive on (date): Sept 20, 1911

And that death occurred on the date stated above at (time AM/PM): 11 PM

THE CAUSE OF DEATH was as follows: Interssuseption

 

(Duration)

Years:

Months:

Days: 4

Signed (M.D.): W H Lucas

Date: Sept 21, 1911

Address: McQuady 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 Cave Springs Church

DATE OF BURIAL: Sept 21, 1911

20.   UNDERTAKER: E F Lyons

ADDRESS: McQyady