1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Glen Dean
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5319
File No. 29824
Registered No:
1. FULL NAME: William Richard Jones
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: Apr 4, 1910
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 2yrs8mos14ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Ky
9. NAME OF FATHER: Richard W Jones
10. BIRTHPLACE OF FATHER: Ind
11. MAIDEN NAME OF MOTHER: Daisy Bowmer
12. BIRTHPLACE OF MOTHER: Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Richard W Jones
(Address) Glendeane
14. Filed Dec 18, 1912
REGISTAR: Mrs. MD Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Dec 18, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Dec 14, 1912 to Dec 18, 1912
That I last saw him/her alive on (date): Dec 18, 1912
And that death occurred on the date stated above at (time AM/PM): 7AM
THE CAUSE OF DEATH was as follows:
Spasmodic Croup
(Duration)
Years:
Months:
Days: 4
Signed (M.D.): PE Dempster
Date: Dec 18, 1912
Address: Glen Dean, 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: Baptist Cemetery
DATE OF BURIAL: Dec 19, 1912
19. UNDERTAKER: H Wilson & Co
ADDRESS: Glen Dean, Ky