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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.:  Bewleyville
Inc Town:  Bewleyville
City:  
No.  
St.  
Ward:  
Registration District No.:  5313
Primary Registration District No:  
File No.  261
Registered No:  1 or x ?
2.	FULL NAME:  Legrand, John
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  male
4.	COLOR OR RACE:  white
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6.	DATE OF BIRTH:  Aug 12, 1857
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  53 yrs  5 mos  14 ds.
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Breckinridge, KY
10.	NAME OF FATHER:  Davis Legrand
11.	BIRTHPLACE OF FATHER:  Hardin Co , KY
12.	MAIDEN NAME OF MOTHER:  Polly Dowell  ?
13.	BIRTHPLACE OF MOTHER:  Breckinridge, KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Therman Lockard
(Address)  Custer
15.	Filed  2/2/1911
REGISTAR:  John Compton
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Jan. 26, 1911
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 16, 1911 to Jan. 26, 1911
That I last saw him/her alive on (date):  Jan 26, 1911
And that death occurred on the date stated above at (time AM/PM):  11 A.M.
THE CAUSE OF DEATH was as follows:  
Pheumonia
(Duration)   Years:            Months:            Days:  10
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. W. & R. W. Meador
Date:  Feb 2, 1911
Address:  Custer
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:  Johnson Burying Ground
DATE OF BURIAL:  Jan 27, 1911
20.	UNDERTAKER:  R. O. Penick
ADDRESS:  Custer, KY

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Copyright.  All rights reserved.
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