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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  5306
Inc Town:  
City:  Cloverport
No.  
St.  
Ward:  2
Registration District No.:  [unreadable]
Primary Registration District No:  5306
File No.  9448
Registered No:  147
2. FULL NAME:  
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  colored
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  July 4, 1881
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  32 years, 9 months, 20 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  chauffeur
(b.)  General nature of industry business or establishment which employed:  automobiles
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  George Owen
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Hannah Wickliffe
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Harvey Owen
(Address)  Cloverport, Ky
15. Filed  Apr. 25, 1914
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  April 24, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  Mar. 1 to Apr. 24, 1914
That I last saw him/her alive on (date):  Apr. 15, 1914
And that death occurred on the date stated above at (time AM/PM):  10:20 PM
THE CAUSE OF DEATH was as follows:  Syphilitic ulceration of the oesophagus
 
(Duration)   Years:      1      Months:            Days:  
Contributory:  Tertiary Syphilis
 
(Duration)   Years:   2         Months:            Days:  
Signed (M.D.):  C.R. Lightfoot
Date:  April 25, 1914
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:  Breckenridge Co.
DATE OF BURIAL:  April 25, 1914
20. UNDERTAKER:  M. Hammon & Sib
ADDRESS:  Cloverport, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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