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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge, Ky
Vot. Pol.:  Rock Vale, Ky
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  135
Primary Registration District No:  5320
File No.  11583
Registered No:  
2. FULL NAME:  Wm. E. Pool
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Apr. 17, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 mos.
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ky.
10. NAME OF FATHER:  James Wm. Pool
11. BIRTHPLACE OF FATHER:  Breckinridge Co., Ky
12. MAIDEN NAME OF MOTHER:  Bettie Skaggs
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  James Wm. Pool
(Address)  Rock Vale, Ky
15. Filed  May 18, 1911
REGISTAR:  E. L. Robertson
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  May 17, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  May 14, 1911 to May 16, 1911
That I last saw him/her alive on (date):  May 16, 1911
And that death occurred on the date stated above at (time AM/PM):  6 a.m.
THE CAUSE OF DEATH was as follows:  Marasmus

(Duration)   Years:            Months:            Days:  25 ds
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P. E. Dempster, M.D.
Date:  May 17, 1911
Address:  Glen Dean, 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:  Owens Grave Yard
DATE OF BURIAL:  May 18, 1911
20. UNDERTAKER:  Steve Pool
ADDRESS:  Glendean, Ky
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Copyright.  All rights reserved.
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