1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  #11

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  2959

Registered No:  5311

2.       FULL NAME:  MAYS, THOMAS H.

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  MALE

4.       COLOR OR RACE:  WHITE

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE

6.       DATE OF BIRTH:  1 / 14 / 1877   

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  34 / 1 / 3 

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER

(b.)  General nature of industry business or establishment which employed:  

9.       BIRTHPLACE:  BRECKINRIDGE CO

10.   NAME OF FATHER:  J.R. MAYS

11.   BIRTHPLACE OF FATHER:  CLOVERPORT

12.   MAIDEN NAME OF MOTHER:  MOLLIE BOHLES

13.   BIRTHPLACE OF MOTHER:  CLOVERPORT

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  J.R. MAYS

(Address)  WEBSTER, KY

15.   Filed  2 – 17 - 11

REGISTAR:  H. DRANE

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  2 – 17 - 11

17.   I HEREBY CERTIFY, That I attended deceased from (date):  2/7/1911 to 2/17/1911

That I last saw him/her alive on (date):  2/16/1911

And that death occurred on the date stated above at (time AM/PM):  

THE CAUSE OF DEATH was as follows:  CONGESTION OF LUNG – CORONARY HEART FAILURE

 

(Duration)   Years:            Months:            Days:  

Contributory:  EXPOSURE

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  T.J. HENDRICK

Date:  2/17/1911

Address:  WEBSTER

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:  WEBSTER, KY

DATE OF BURIAL:  2/18/1911

20.   UNDERTAKER:  G. DURRELL

ADDRESS:  IRVINGTON