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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.:  Mook
Inc Town:  
City:  
No. 
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5317
File No.  25017
Registered No:  5317
2. FULL NAME:  John Pile
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  Black
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widower
6. DATE OF BIRTH:  
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ky.
10. NAME OF FATHER:  Wilse Pile
11. BIRTHPLACE OF FATHER:  Ky.
12. MAIDEN NAME OF MOTHER:  Celia Carter
13. BIRTHPLACE OF MOTHER:  Ky.
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Wm. Pool
(Address)  Mook, Ky.
15. Filed  Oct 19, 1911
REGISTAR:  V. G. Goodman
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Oct. 19, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Oct. 14, 1911 to Oct. 18, 1911
That I last saw him/her alive on (date):  Oct. 15, 1911
And that death occurred on the date stated above at (time AM/PM):  11 a.m.
THE CAUSE OF DEATH was as follows:  Enemia

(Duration)   Years:            Months:            Days:  5
Contributory:  to chronic nephritis

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. E. Matthews, M.D.
Date:  
Address:  Westview, 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:  Pile grave yard
DATE OF BURIAL:  Oct 19, 1911
20. UNDERTAKER:  W. M. Pool
ADDRESS:  Racine

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Copyright.  All rights reserved.
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