************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: MOOK Inc Town: MOOK City: No. St. Ward: Registration District No.: Primary Registration District No: File No. 22687 Registered No: 18 1. FULL NAME: ROBINSON, BURTON M. PERSONAL AND STATICAL PARTICULARS 2. SEX: MALE 3. COLOR OR RACE: WHITE 4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 5. DATE OF BIRTH: JUN 9, 1894 6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 16 / 17 / 17 7. OCCUPATION (a.) Trade, profession or particular kind of work: FARMING (b.) General nature of industry business or establishment which employed: 8. BIRTHPLACE: BRECKINRIDGE 9. NAME OF FATHER: ROBBIE ROBINSON 10. BIRTHPLACE OF FATHER: BRECKINRIDGE 11. MAIDEN NAME OF MOTHER: VIRINDA GALLOWAY 12. BIRTHPLACE OF MOTHER: BRECKINRIDGE 13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) ROBBIE ROBINSON (Address) MOOK 14. Filed SEP 27, 1911 REGISTAR: M.M. JARBOE MEDICAL CERTIFICATE OF DEATH 15. DATE OF DEATH: SEP 26, 1911 16. I HEREBY CERTIFY, That I attended deceased from (date): SEP 12, 1911 to SEP 26, 1911 That I last saw him/her alive on (date): SEP 12, 1911 And that death occurred on the date stated above at (time AM/PM): 9 AM THE CAUSE OF DEATH was as follows: ENDOCARDITIS (Duration) Years: 3 Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): J.C. TUCKER Date: JUN 26, 1911 Address: MCDANIELS 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: ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************