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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Hardinsburg
Inc Town:  [unreadable]
City:  
No.  
St.  
Ward:  
Registration District No.:  138
Primary Registration District No:  5303
File No.  6359
Registered No:  161
2. FULL NAME:  Sam Pool
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  black
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widowed
6. DATE OF BIRTH:  Don't know month 1838
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  75 years
8. OCCUPATION (a.) Trade, profession or particular kind of work:  pauper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  [blank]
11. BIRTHPLACE OF FATHER:  [blank]
12. MAIDEN NAME OF MOTHER:  [blank]
13. BIRTHPLACE OF MOTHER:  [blank]
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  William Wheeler
(Address)  Hardinsburg, Ky
15. Filed  mar 19, 1913
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Mar 18, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  10 AM
THE CAUSE OF DEATH was as follows:  [unreadable] Hear Disease
 
(Duration)   Years:            Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Jno E. Kincheloe
Date: Mar 18, 1913
Address:  Hardinsburg, Ky
18. LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)
At place of death (yr, mo, da.):   2 years
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:  Pauper Cemetery
DATE OF BURIAL:  Mar 19, 1913
20. UNDERTAKER:  [unreadable]
ADDRESS:  Hardinsburg, Ky
 

ADDITIONAL COMMENTS/NOTES:
(3131) is written in above the file number
 
 

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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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