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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.: ROCKVALE 
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5320
Primary Registration District No:  
File No.  9528  [SMEARED]
Registered No:  
2.	FULL NAME:  SALMONS, DAUGHTER
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  APR 29, 1913
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  5 HRS
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE 
10.	NAME OF FATHER:  CORDIE SALMONS
11.	BIRTHPLACE OF FATHER: GRAYSON CO 
12.	MAIDEN NAME OF MOTHER:  TINTE [??] CLEMMONS  [HARD TO READ]
13.	BIRTHPLACE OF MOTHER:  BRECKINRIDGE CO
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  MRS. JOSIE CLEMMONS
(Address)  
15.	Filed  APR 29, 1913
REGISTAR:  J. McDONOUGH
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  APR 29, 1913
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:  SHOCK OF BIRTH
(Duration)   Years:            Months:            Days:    
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  MRS. JOSIE CLEMMONS, MOTHER OF GIRL
Date:  
Address:  VAN ZANDT, KENTUCKY
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:  MACEDONIA CEM
DATE OF BURIAL:  APR 30, 1913
20.	UNDERTAKER:  
ADDRESS:  


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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