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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  McDaniels
Inc Town:  
City:  
No. 
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5318
File No.  27313
Registered No:  
2. FULL NAME:  Charles Pearl
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widowed
6. DATE OF BIRTH:  Aug. 13, 1848
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  63 yrs  1 mos  28 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Grayson Co., Ky
10. NAME OF FATHER:  Geo. Pearl
11. BIRTHPLACE OF FATHER:  Grayson Co., Ky
12. MAIDEN NAME OF MOTHER:  Nancy Lungley
13. BIRTHPLACE OF MOTHER:  Grayson Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. W. Storms
(Address)  McDaniels
15. Filed  Oct 11, 1911	
REGISTAR:  M. M. Jarboe
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  October 11, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Sept 30, 1911 to Oct. 8, 1911
That I last saw him/her alive on (date):  Oct. 8, 1911
And that death occurred on the date stated above at (time AM/PM):  9 p.m.
THE CAUSE OF DEATH was as follows:  Intestinal Tuberculosis

(Duration)   Years:  about 1          Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. B. Lampton  M.D.
Date:  Oct. 12, 1911
Address:  McDaniels, 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:  
DATE OF BURIAL:  
20. UNDERTAKER:  
ADDRESS:  

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Copyright.  All rights reserved.
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