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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:  Breckenridge
Vot. Pol.:  Nat. 5305
Inc Town:  
City:  Cloverport, KY
No.  
St.  
Ward:  1st
Registration District No.:  131
Primary Registration District No:  2065
File No.  5630
Registered No:  9
2.  FULL NAME:  Still Born
PERSONAL AND STATICAL PARTICULARS
3.  SEX:  Male
4.  COLOR OR RACE:  White
5.  SINGLE, MARRIED, WIDOWED, OR DIVORCED:  None
6.  DATE OF BIRTH:  March 27, 1911
7.  AGE  (yr. mo. da) (If less than 1 day, hours or min?):  Stillborn
8.  OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.  BIRTHPLACE:  Cloverport, Ky
10.  NAME OF FATHER:  Wm Perrin
11.  BIRTHPLACE OF FATHER:  Cloverport
12.  MAIDEN NAME OF MOTHER:  Ella Smith
13.  BIRTHPLACE OF MOTHER:  Cloverport
14.  THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Gobr Perrin
(Address)  Holt, Ky
15.  Filed  Mch 31, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16.  DATE OF DEATH:  March 27, 1911
17.  I HEREBY CERTIFY, That I attended deceased from (date):  Mch 27, 1911 to Mch 27, 1911
That I last saw him alive on (date):  Mch 27, 1911
And that death occurred on the date stated above at (time AM/PM):  PM
THE CAUSE OF DEATH was as follows:  Stillborn.  Premature accidental {illegible} traumotis

(Duration)   Years:            Months:            Days:  
Contributory:  Accidental injury to mother

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  F. L. Lightfoot
Date:  3/31, 1911
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:  Holt
DATE OF BURIAL:  Mch 27, 1911
20.  UNDERTAKER:  
ADDRESS:  


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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