************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ 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: ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************