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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  5307

Inc Town:  CLOVERPORT

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  27663

Registered No: 44

2.       FULL NAME:  SANDERS, WILLIAM T.

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     MALE

4.       COLOR OR RACE:  WHITE

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED

6.       DATE OF BIRTH: JUN 26, 1870

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  41 / 4 / 28

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

(b.)  General nature of industry business or establishment which employed:  FARM WORK & DRAYING

9.       BIRTHPLACE:  INDIANA

10.   NAME OF FATHER:  THOMAS SANDERS

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  AMANDA RUSHER

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  ALLEN W. SANDERS

(Address)  EVANSVILLE, IN

15.   Filed  NOV 25, 1911

REGISTAR:  J.C. NOLTE

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  NOV 24, 1911

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):  1830  [6:30 PM]

THE CAUSE OF DEATH was as follows:  ACCIDENTAL DEATH – HEAD CRUSHED IN MOVING AN ENGINE – DIED INSTANTLY

(Duration)   Years:            Months:            Days:  

Contributory:  

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  GEORGE N. HARRIS, MAGISTRATE

Date:  NOV 25, 1911

Address:  CLOVERPORT

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:  CLOVERPORT

DATE OF BURIAL:  NOV 25, 1911

20.   UNDERTAKER:  M. HAMMON & SON

ADDRESS:  CLOVERPORT

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