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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.: McDaniels, Ky
Inc Town:
City: Mook, Ky
No. 5318
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 14281
Registered No:
1. FULL NAME: Dwight (Clement) Pullen
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED:
5. DATE OF BIRTH: June 29, 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): Infant
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Breckinridge Co, Ky
9. NAME OF FATHER: Stephen Pullen
10. BIRTHPLACE OF FATHER: Madrid, Ky
11. MAIDEN NAME OF MOTHER: Vera Tucker
12. BIRTHPLACE OF MOTHER: Mook, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) E.H. Tucker
(Address) Mook, Ky
14. Filed
REGISTAR:
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: June 20, 1911
16. 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):
THE CAUSE OF DEATH was as follows:
Premature labor
(Duration)
Years:
Months:
Days:
Signed (M.D.): J.C. Tucker
Date: June 20, 1911
Address: McDaniels, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: near Salem
DATE OF BURIAL:
19. UNDERTAKER:
ADDRESS:

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