************************************************************************
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
************************************************