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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  5307
Inc Town:  
City:  Cloverport, Ky
No.  
St.  
Ward:  3
Registration District No.:  131
Primary Registration District No:  2065
File No.  21016
Registered No:  119
2.	FULL NAME:  Robert Nicholas
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Male
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6.	DATE OF BIRTH:  May 15, 1835
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  78 yrs  3 mos  2 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer-Retired
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  New York
10.	NAME OF FATHER:  Don’t Know
11.	BIRTHPLACE OF FATHER:  Don’t Know 
12.	MAIDEN NAME OF MOTHER:  Don’t Know 
13.	BIRTHPLACE OF MOTHER:  Don’t Know 
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  T. S. Nicholas
(Address)  Cloverport, Ky
15.	Filed  Aug. 15, 1913
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Aug. 15, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  July 20, 1913 to Aug. 15, 1913
That I last saw him/her alive on (date):  Aug. 12th, 1913
And that death occurred on the date stated above at (time AM/PM):  11:30 a.m.
THE CAUSE OF DEATH was as follows:  Dysentery

(Duration)   Years:            Months:  2          Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  C. R. Lightfoot, M.D.
Date:  Aug. 16, 1913
Address:  Cloverport, 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:  Cloverport, Ky
DATE OF BURIAL:  Aug. 1?, 1913
20.	UNDERTAKER:  M. Hamman Sons
ADDRESS:  Cloverport, Ky


ADDITIONAL COMMENTS/NOTES:




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