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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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1.       PLACE OF DEATH

County: Breckinridge

Vot. Pol.: Hardinsburg KY

Inc Town:

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 27037

Registered No: 132

2.       FULL NAME:

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: Black

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single

6.       DATE OF BIRTH: Nov 12, 1912

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 17 da

8.       OCCUPATION (a.) Trade, profession or particular kind of work: at home

(b.)  General nature of industry business or establishment which employed:

9.       BIRTHPLACE: Kentucky

10.   NAME OF FATHER: Horace Robards

11.   BIRTHPLACE OF FATHER: Kentucky

12.   MAIDEN NAME OF MOTHER: Maggie Dran

13.   BIRTHPLACE OF MOTHER: Kentucky

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant) Ernest Dran

(Address) Hardinsburg kY

15.   Filed Nov 30, 1912

REGISTAR: W B Lennon

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Nov 29, 1912

17.   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:  Convulsions, dead when I saw him.

 

(Duration) 

Years:

Months:

Days:

Signed (M.D.): Jno E Kincheloe

Date: Nov 29, 1912

Address: Hardinsburg 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  Hardinsburg Cemetery

DATE OF BURIAL: Nov 30, 1912

20.   UNDERTAKER: Geo Mattinly

ADDRESS: Kirk KY





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Copyright.  All rights reserved.
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