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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.:  BALLTOWN
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  27673
Registered No: 12 
2. FULL NAME:  MATTINGLY, LEO
PERSONAL AND STATICAL PARTICULARS
3. SEX:  MALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  MARCH 1906
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  5 YRS
8. OCCUPATION (a.) Trade, profession or particular kind of work:  CHILD
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  MATTINGLY, KY
10. NAME OF FATHER:  JOHN S. MATTINGLY
11. BIRTHPLACE OF FATHER:  KENTUCKY
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)  JOE M. MATTINGLY
(Address)  MATTINGLY, KY
15. Filed  NOV 25, 1911
REGISTAR:  FRED FRANK
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  NOV 18, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  NOV 14, 1911 to NOV 18, 1911
That I last saw him/her alive on (date):  18 NOV 1911
And that death occurred on the date stated above at time AM/PM):  1:30 PM
THE CAUSE OF DEATH was as follows:  PNEUMONIA

(Duration)   Years:            Months:            Days:  4 
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  W.H. LUCAN
Date:  NOV 19, 1911
Address:  MC QUADY, 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 MARY’S CEM
DATE OF BURIAL:  NOV 20, 1911
20. UNDERTAKER:  E.F. LYONS
ADDRESS:  MC QUADY, KY

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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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