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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  No. 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:  Married
6. DATE OF BIRTH:  March 27, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  Still born
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. Pierce
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)  Gabe Pierce
(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/her alive on (date):  Mch. 27, 1911
And that death occurred on the date stated above at (time AM/PM):  p.m.
THE CAUSE OF DEATH was as follows:  Still born. Premature, Accidental, Labor Traumatica

(Duration)   Years:            Months:   1         Days:  
Contributory:  Accidental injury to mother

(Duration)   Years:            Months:  1          Days:  
Signed (M.D.):  F. L. Lightfoot  M.D.
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.
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