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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Union Star, Ky
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5309
Primary Registration District No:  
File No.  27966
Registered No:  
2. FULL NAME:  John Salmon
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  [blank]
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  2 months 17 dyas
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., Ky
10. NAME OF FATHER:  Elisha Salmon
11. BIRTHPLACE OF FATHER:  Grayson County, Ky
12. MAIDEN NAME OF MOTHER:  Maude Duke
13. BIRTHPLACE OF MOTHER:  Grayson County, Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Jess Salmon
(Address)  Mystic, Ky
15. Filed  Nov. 30, 1914
REGISTAR:  Lee Stevens
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Nov. 29, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  Nov 16 to Nov 16, 1914
That I last saw him/her alive on (date):  Nov 16, 1914
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  Indigestion
 
(Duration)   Years:            Months:            Days:  16
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Wm L. Milner
Date:  11/30/1914
Address:  Union Star, 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:  Walnut Grove Burying Ground
DATE OF BURIAL:  Nov. 30, 1914
20. UNDERTAKER:  P. H. Beauchamp
ADDRESS:  Mystic, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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