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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5302
File No.  31014
Registered No:  
2. FULL NAME:  John K. Langly
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  Nov 10, 1913
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  2 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Infant
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Felix Langly
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Mary Harper
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Pete Shuan
(Address)  Kirk, Ky
15. Filed  Dec 11, 1913
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Nov. 12, 1913 [stamped with] DELAY
17. I HEREBY CERTIFY, That I attended deceased from (date):  Nov 10 through Nov 12, 1913
That I last saw him/her alive on (date):  Nov 10, 1913
And that death occurred on the date stated above at (time AM/PM):  7 ?m
THE CAUSE OF DEATH was as follows:  premature birth
 
(Duration)   Years:            Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  John E. Knicheloe
Date:  Nov 13, 1913
Address:  Hardinsburg, 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:  
DATE OF BURIAL:  De Haven Cemetery
20. UNDERTAKER:  George Mattingly
ADDRESS:  Kirk, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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