1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Madrid, Ky
Inc Town:
City:
No. 5316
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 27670
Registered No: 19
1. FULL NAME: Robert L. Mercer
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: June 5, 1875
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 36yrs5mos25ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: Farmer
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Ky
9. NAME OF FATHER: Joseph D Mercer
10. BIRTHPLACE OF FATHER: Ky
11. MAIDEN NAME OF MOTHER: Susan Lampton
12. BIRTHPLACE OF MOTHER: Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Jas H Carman
(Address) Madrid Ky
14. Filed 12/1/1911
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: 11/30/1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Sept 12, 1911 to Nov 30, 1911
That I last saw him/her alive on (date): Sept 12, 1911
And that death occurred on the date stated above at (time AM/PM):
THE CAUSE OF DEATH was as follows:
Pulmonary Tuberculosis
(Duration)
Years: 5
Months: 6
Days: 18
Signed (M.D.): S.J. Hall
Date: 12/1/1911
Address: Constantine, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Coyles Grave Yd
DATE OF BURIAL: 12/1/1911
19. UNDERTAKER: John Pullen
ADDRESS: Madrid Ky