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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.: Webstfield

Inc Town: Hardinsburg

City:

No.

St.

Ward

Registration District No.: 5311

Primary Registration District No:

File No. 5634

Registered No: 

2.       FULL NAME: Charlie Daniel Hook

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: Colored

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

6.       DATE OF BIRTH: 1888

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 22 yrs

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

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

9.       BIRTHPLACE: Irvington Breck Co., KY

10.   NAME OF FATHER: Daniel Hook

11.   BIRTHPLACE OF FATHER: Hardinsburg Breck Co., KY

12.   MAIDEN NAME OF MOTHER: Delia Dojrich

13.   BIRTHPLACE OF MOTHER: Bewleyville Breck Co., KY

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

(Informant) George Hook

(Address) Garfield KY

15.   Filed 3/18, 1911

REGISTAR: H Drane

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: March 14, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date): Sept 10, 1911 to Dec 7, 1911

That I last saw him/her alive on (date): Dec 7, 1911

And that death occurred on the date stated above at (time AM/PM): 9 AM Mar 14, 1911

THE CAUSE OF DEATH was as follows: Tuberculosis of the lungs

 

(Duration)

Years:

Months: 5

Days: 10

Signed (M.D.): J A Sandbach

Date: Mar 14, 1911

Address: Garfield 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 Hooks Burial Ground

DATE OF BURIAL: Mar 15, 1911

20.   UNDERTAKER: A A Richardson & Son

ADDRESS: Garfield, KY

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Copyright.  All rights reserved.
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