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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.:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward  2

Registration District No.:  

Primary Registration District No:  

File No.   25003

Registered No:  60 

2.       FULL NAME:  HUMBLE, HENRY

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  MALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  DON’T KNOW

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  DON’T KNOW

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:  ROCK HAVEN, MEADE CO, 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)  R.R. KENNEDY

(Address)  GARFIELD, KY

15.   Filed  OCT 4, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: OCT 4, 1911 

17.   I HEREBY CERTIFY, That I attended deceased from (date):  OCT 3, 1911 to OCT 4, 1911

That I last saw him/her alive on (date):  OCT 3, 1911

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

THE CAUSE OF DEATH was as follows:  ACUTE INDIGESTION

 

(Duration)  

Years:  

Months:  

Days:   1 DAY

Signed (M.D.):  J.A. DANDBACK

Date:  OCT 4, 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  FREEDOM CEMETERY

DATE OF BURIAL:  OCT 5, 1911

20.   UNDERTAKER:  J.R. RICHARDSON

ADDRESS:  GARFIELD, KY

NOTE:  THIS MAN HAD NO RELATIVES AND WE DON’T KNOW HIS AGE OR DEATE OF BIRTH
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Copyright.  All rights reserved.
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