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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.: No 9

Inc Town:

City:

No.

St.

Ward

Registration District No.: 5309

Primary Registration District No:

File No. 22678

Registered No: 8

2.       FULL NAME:

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: white

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

6.       DATE OF BIRTH: Oct 13, 1909

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 2 yrs

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

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

9.       BIRTHPLACE: Breckinridge Co KY

10.   NAME OF FATHER: Grose Howard

11.   BIRTHPLACE OF FATHER: Kentucky

12.   MAIDEN NAME OF MOTHER: Martha Hohimer

13.   BIRTHPLACE OF MOTHER: Ohio

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

(Informant) Victoria Masterson

(Address) Ammons KY

15.   Filed Sept 14, 1911

REGISTAR: Lee Stewart by R.A. Sullivan

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Sept 6, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date): July 11, 1911 to Aug 21, 1911

That I last saw him/her alive on (date): Aug 21, 1911

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

THE CAUSE OF DEATH was as follows: Tuberculosis Pulmonary

 

(Duration) 

Years: 2

Months:

Days:

Contributory: Acute Nephritis

(Duration)

Years: 

Months: 7

Days:

Signed (M.D.): Geo. E. Shively    

Date: 9/6, 1911

Address: Stephensport 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: Shellman burying ground

DATE OF BURIAL: Sept 6, 1911

20.   UNDERTAKER: W.J. SCHOFF

ADDRESS: Stephensport KY

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Copyright.  All rights reserved.
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************************************************