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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
Vot. Pol.:
Inc Town: Glendeane
City:
No.
St.
Ward
Registration District No.: 132
Primary Registration District No: 5319
File No. 5642
Registered No:
1. FULL NAME: Still Birth Raymer
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: still birth
5. DATE OF BIRTH: Mar 24, 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): still born
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: J.T. Raymer
10. BIRTHPLACE OF FATHER: Butler Co, Ky
11. MAIDEN NAME OF MOTHER: Martha Finley
12. BIRTHPLACE OF MOTHER: Butler Co, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) J.T. Raymer
(Address) Glendeane, Ky
14. Filed Mar 24, 1911
REGISTAR: E.L. Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Mar 24, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Mar 24, 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:
Still born
(Duration)
Years:
Months:
Days:
Signed (M.D.): R.T. Dempster
Date: Mar 24, 1911
Address: Glen Dean
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:
19. UNDERTAKER:
ADDRESS:

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Copyright.  All rights reserved.
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