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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Stephensport, KY
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  18700
Registered No:  24
2. FULL NAME:  Edward McCoy
PERSONAL AND STATICAL PARTICULARS
3. SEX:  boy
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  May 27, 1912
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  2 years
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  [blank]
10. NAME OF FATHER:  Linn McCoy
11. BIRTHPLACE OF FATHER:  
12. MAIDEN NAME OF MOTHER:  Edna Compton
13. BIRTHPLACE OF MOTHER:  Garfield, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Chas Compton
(Address)  Stephensport, KY
15. Filed  Aug 10, 1912
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 27, 1912 [Delayed stamped near date]
17. I HEREBY CERTIFY, That I attended deceased from (date):  July 6 to July 26, 1912
That I last saw him/her alive on (date):  July 24, 1912
And that death occurred on the date stated above at (time AM/PM):  9 PM
THE CAUSE OF DEATH was as follows:  Intero Colitis
 
(Duration)   Years:            Months:      1      Days:  
Contributory:  Tuberculoses
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Geo E. Shirley
Date:  Aug 10, 1912
Address:  Stephensport, 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:  Near Stephensport, KY
DATE OF BURIAL:  July 27, 1912
20. UNDERTAKER:  W. J. Schopps
ADDRESS:  Stephensport
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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