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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.:  BALLTOWN

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  22689

Registered No: 9

2.       FULL NAME:  ROBINSON, AYTEH

PERSONAL AND STATICAL PARTICULARS

3.       SEX:     MALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  OCT 3, 1844

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  67 / 11 / 1

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

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  DANIEL BOON ROBINSON

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  ELIZABETH BARCLAY

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  

(Address)  

15.   Filed  SEP 5, 1911  

REGISTAR:  FRED FRANK

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  SEP 4, 1911

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:  UNKNOWN – WAS DETERMINED BY CORONER JURY

 

(Duration)   Years:            Months:            Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  G.N. HARRIS, J.P.

Date:  

Address:  

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:  TARFORK

DATE OF BURIAL:  SEP 5, 1911

20.   UNDERTAKER:  M. HAMMON & SONS

ADDRESS:  CLOVERPORT

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Copyright.  All rights reserved.
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