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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.:  5306

Inc Town:  CLOVERPORT

City:  

No.  

St.  

Ward:  2

Registration District No.:  

Primary Registration District No:  

File No. 20123 

Registered No:  30

2.       FULL NAME:  JENNINGS, CHARLES L.

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  MALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  DEC 29, 1849

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  61 / 7 /18

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  KEEPER OF TOLL GATE

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  LEWIS JENNINGS

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  MARGARETTE HARRIS

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  LETITIA CHAPIN

(Address)  CLOVERPORT, KY

15.   Filed  AUG 17, 1911

REGISTAR:  J.C. NOLTE

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  AUG 17, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  AUG 13, 1911 to AUG 17, 1911

That I last saw him/her alive on (date):  AUG 17, 1911

And that death occurred on the date stated above at (time AM/PM):  10 AM

THE CAUSE OF DEATH was as follows:  ACUTE CONGESTION OF KIDNEYS

 

(Duration)   Years:            Months:            Days:  

Contributory:  ACUTE UREMIA

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  F.L. LIGHTFOOT

Date:  AUG 17, 1911

Address:  CLOVERPORT

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:  BRECKINRIDGE CO

DATE OF BURIAL:  AUG 18, 1911

20.   UNDERTAKER:  M HAMMOND & SON

ADDRESS:  CLOVERPORT


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Copyright.  All rights reserved.
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