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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:
Vot. Pol.: Breckinridge
Inc Town: Rockvale
City:
No.
St.
Ward
Registration District No.: 132
Primary Registration District No: 5320
File No. 11262
Registered No:
1. FULL NAME: Still Birth
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED:
5. DATE OF BIRTH: April 25, 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?):
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: Jas. Joseph Quiggins
10. BIRTHPLACE OF FATHER: Grayson Co, Ky
11. MAIDEN NAME OF MOTHER: Mary E. Scaggs
12. BIRTHPLACE OF MOTHER: Breckinridge Co, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Joe Quiggins
(Address) Falls of Rough
14. Filed Apr 26, 1911
REGISTAR: E.C. Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: April 25, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): April 25, 1911
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:
Prematurely born about 5th month of gestation
(Duration)
Years:
Months:
Days:
Signed (M.D.): JB Lampton
Date: April 25, 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
DATE OF BURIAL: Apr 25, 1911
19. UNDERTAKER:
ADDRESS:
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