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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Glen Dean
Inc Town:  
City:  Glen Dean
No.  
St.  
Ward:  
Registration District No.:  132
Primary Registration District No:  5319
File No.  11266
Registered No:  
2. FULL NAME:  Osborne, Paul Dempster
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  July 27, 1899
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  17 yr 8 mo 25 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Schoolboy
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  Mike Osborne
11. BIRTHPLACE OF FATHER:  IN
12. MAIDEN NAME OF MOTHER: Roda Davis 
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Mike Osborne
(Address)  Glen Dean, KY
15. Filed  Apr. 22, 1911
REGISTAR:  E. L. Robertson
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Apr. 21, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  March 31, 1911
That I last saw him/her alive on (date):  Apr. 20, 1911
And that death occurred on the date stated above at (time AM/PM):  3 PM
THE CAUSE OF DEATH was as follows:  Bronchopneumonia

(Duration)   Years:            Months:            Days:  3
Contributory:  Measles

(Duration)   Years:            Months:            Days:  19
Signed (M.D.):  R. T. Dempster
Date:  Apr. 22, 1911
Address:  Glen Dean, 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:  Union Chapel Burial Ground
DATE OF BURIAL:  Apr. 22, 1911
20. UNDERTAKER:  W. C. Moorman
ADDRESS:  

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Copyright.  All rights reserved.
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