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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  HUDSON
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5316
Primary Registration District No:  
File No.  54877
Registered No:  
2.	FULL NAME:  NICHOLS, HENRY
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  UNKNOWN 1879
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  35 / - / -
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  WILLIAM NICHOLS
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  LUCAS
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  GUY D. JOHNSON
(Address)  HUDSON
15.	Filed  JUN 14, 1914
REGISTAR:  J.H. COMER
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  JUN 14, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  JUN 13, 1914 tO JUN 14, 1914
And that death occurred on the date stated above at (time AM/PM):  1:30 PM
THE CAUSE OF DEATH was as follows:  SHOCK
(Duration)   Years:            Months:            Days:   21 1/2 HRS 
Contributory:  GUNSHOT WOUND IN KNEE
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  S.J. HACE
Date:  JUN 14, 1914
Address:  CONSTANTINE
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:  NICHOLS CEM
DATE OF BURIAL:  JUN 15, 1914
20.	UNDERTAKER:  LONNIE ALLEN
ADDRESS:  HUDSON


ADDITIONAL COMMENTS/NOTES:




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