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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.: Bewleyville

Inc Town:

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 19024

Registered No: 0

2.       FULL NAME: James Ross

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:

6.       DATE OF BIRTH: Feb 5, 1912

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 6 mos 10 da

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

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

9.       BIRTHPLACE: Breckinrigde Co KY

10.   NAME OF FATHER: Ed Ross

11.   BIRTHPLACE OF FATHER: Breckinridge Co KY

12.   MAIDEN NAME OF MOTHER: Annie Vititoe

13.   BIRTHPLACE OF MOTHER: Hardin Co KY

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

(Informant) W V Dent

(Address) Irvington KY

15.   Filed 8/20, 1912

REGISTAR: John Compton

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: 8-15, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Aug 12, 1912 to Aug 15, 1912

That I last saw him/her alive on (date): August 16, 1912

And that death occurred on the date stated above at (time AM/PM): 1:15 AM

THE CAUSE OF DEATH was as follows: Entero Colitis

 

(Duration)

Years:

Months:

Days: 3

Signed (M.D.): P W Foot

Date: Aug 16, 1912

Address: Irvington 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 Bethel

DATE OF BURIAL: Aug 16, 1912

20.   UNDERTAKER: G T Marshall & Son

ADDRESS: Irvington KY


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Copyright.  All rights reserved.
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