1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hudson
Inc Town:
City:
No. 5316
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 42963
Registered No: 4
1. FULL NAME: Sidney Amon Mercer
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: caucasion
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: October 23, 1910
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 3mos23ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Kentucky
9. NAME OF FATHER: JE Mercer
10. BIRTHPLACE OF FATHER: Breckinridge, Ky
11. MAIDEN NAME OF MOTHER: Laura Carwile
12. BIRTHPLACE OF MOTHER: Breckinridge, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Zetro Carwile
(Address) Fisher, Ky
14. Filed 2/20/1911
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: February 15, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Feb 14, 1911 to Feb 15, 1911
That I last saw him/her alive on (date): Feb 15, 1911
And that death occurred on the date stated above at (time AM/PM): 10 PM
THE CAUSE OF DEATH was as follows:
Lobar Pneumonia
(Duration)
Years:
Months:
Days: 3
Signed (M.D.): JC Tucker
Date: Feb 16, 1911
Address: McDaniels, 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: McDaniels, Ky
DATE OF BURIAL: Feb 17, 1911
19. UNDERTAKER: Rhodes Storm & Co
ADDRESS: McDaniels, Ky