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1. PLACE OF DEATH
County: Breckinridge Co
Vot. Pol.: Glen Dean
Inc Town:
City:
No.
St.
Ward
Registration District No.: 132
Primary Registration District No: 5319
File No. 30088
Registered No:
1. FULL NAME: Lonie Harrison Raymer
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
5. DATE OF BIRTH: Sep 9, 1886
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 25yrs1mo
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Grayson Co, Ky
9. NAME OF FATHER: James R Raymer
10. BIRTHPLACE OF FATHER: Grayson Co, Ky
11. MAIDEN NAME OF MOTHER: Caroline Renolds
12. BIRTHPLACE OF MOTHER: Grayson Co, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) J.R. Raymer
(Address) Glen Dean, Ky
14. Filed Oct 10, 1911
REGISTAR: E.L. Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: October 9, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Sep 17, 1911 to Oct 8, 1911
That I last saw him/her alive on (date): Oct 8, 1911
And that death occurred on the date stated above at (time AM/PM): 9 AM
THE CAUSE OF DEATH was as follows:
Tuberculosis of the lungs
(Duration)
Years: 3 
Months: 3
Days: 9
Signed (M.D.): R.T. Dempster
Date:
Address:
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: Goshen Bur. Ground
DATE OF BURIAL: Oct 10, 1911
19. UNDERTAKER: B.F. Beard & Co
ADDRESS: Hardinsburg, Ky

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Copyright.  All rights reserved.
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