1. PLACE OF DEATH
County: Breck
Vot. Pol.: 12
Inc Town: Irvington, Ky
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5312
File No. 27048 (number underneath-looks like 35)
Registered No: 5312
1. FULL NAME: Othie Jones
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: colored
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: Oct 5, 1879
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 33yrs1mo15ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:Laborer
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Irvington, Ky
9. NAME OF FATHER: Henry Jones
10. BIRTHPLACE OF FATHER: Meade Co, Ky
11. MAIDEN NAME OF MOTHER: Elizabeth Hendrick
12. BIRTHPLACE OF MOTHER: Brandenberg, Ky (Meade Co)
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Henry Jones
(Address) Irvington, Ky
14. Filed Nov 22, 1912
REGISTAR: DW Henry
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Nov 20, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Sept 15, 1912 to Nov 20, 1912
That I last saw him/her alive on (date): 17 Nov, 1912
And that death occurred on the date stated above at (time AM/PM): 5AM
THE CAUSE OF DEATH was as follows:
Tuberculosis of Lungs
(Duration)
Years:
Months: 6
Days:
Signed (M.D.): S.P.Parks
Date: Nov 20, 1912
Address: Irvington, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Irvington, Ky
DATE OF BURIAL: Nov 21, 1912
19. UNDERTAKER: GT Marshall & Son
ADDRESS: Irvington, Ky