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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  #5307
Inc Town:  Cloverport
City:  2065
No.  
St.  
Ward:  
Registration District No.:  131
Primary Registration District No:  2065
File No.  252
Registered No:  
2.	FULL NAME:  Lewis, Paul Edwin
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  male		
4.	COLOR OR RACE:  white
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6.	DATE OF BIRTH:  Jan 5, 1911
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  2ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  infant
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Breckinridge , KY
10.	NAME OF FATHER:  Henry J. Lewis
11.	BIRTHPLACE OF FATHER:  Indiana
12.	MAIDEN NAME OF MOTHER:  Mary E. Mattingly
13.	BIRTHPLACE OF MOTHER:  Kentucky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Henry J. Lewis
(Address)  Cloverport, KY
15.	Filed  Jan. 7, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Jan 7, 1911
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 5, 1911 to Jan. 7, 1911
That I last saw him/her alive on (date):  Jan. 6, 1911
And that death occurred on the date stated above at (time AM/PM):  2:34 P.M. ?
THE CAUSE OF DEATH was as follows:  
Lack of vitality due to premature birth at 6th month
(Duration)   Years:            Months:            Days:  2
Contributory:  
Hemorrhage from stomach
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  A. A. Simons
Date:  Jan 7, 1911
Address:  Cloverport, 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:  St. Rose Cemetery
DATE OF BURIAL:  Jan. 8, 1911
20.	UNDERTAKER:  M. Hammon & Son
ADDRESS:  Cloverport

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Copyright.  All rights reserved.
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