************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: CLOVERPORT, KY Inc Town: City: No. St. Ward: 3 Registration District No.: 5307 Primary Registration District No: 131 File No. 21018 Registered No: 122 2. FULL NAME: HOLT, CARLETON PERSONAL AND STATICAL PARTICULARS 3. SEX: MALE 4. COLOR OR RACE: COLORED 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 6. DATE OF BIRTH: FEB 16, 1897 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 16 YR 7 MO 14 DA 8. OCCUPATION (a.) Trade, profession or particular kind of work: DAY LABORER (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: KY 10. NAME OF FATHER: PRESTON HOLT 11. BIRTHPLACE OF FATHER: KY 12. MAIDEN NAME OF MOTHER: ROSA DEAN 13. BIRTHPLACE OF MOTHER: KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) HUBERT HOLT (Address) CLOVERPORT, KY 15. Filed AUG. 30, 1913 REGISTAR: J. C. NOLTE MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: AUG. 30, 1913 17. I HEREBY CERTIFY, That I attended deceased from (date): AUG. 12, 1913 That I last saw him/her alive on (date): AUG. 29, 1913 And that death occurred on the date stated above at (time AM/PM): 8:30 AM THE CAUSE OF DEATH was as follows: TYPHOID FEVER (Duration) Years: Months: Days: 18 Contributory: (Duration) Years: Months: Days: Signed (M.D.): A. A. SIMONS Date: AUG. 30, 1913 Address: CLOVERPORT, 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: CLOVERPORT, KY DATE OF BURIAL: AUG. 30, 1913 20. UNDERTAKER: M. M. HAMMAN ADDRESS: CLOVERPORT, KY ADDITIONAL COMMENTS/NOTES: ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************