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

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

1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  5307

Inc Town:  CLOVERPORT

City:  2065

No.  2065

St.  

Ward:  3

Registration District No.:  

Primary Registration District No:  

File No. 30572 

Registered No: 47

2.       FULL NAME:  SCOTT, CHARLES ADRIAN

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     MALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH: JAN 15, 1910

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 / 11 / 1

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

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

9.       BIRTHPLACE:  KENTUKCY

10.   NAME OF FATHER:  PEYTON S. SCOTT

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  SOPHRONIA PATE

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  P.S. SCOTT

(Address)  CLOVERPORT

15.   Filed  DEC 16, 1911

REGISTAR:  J.C. NOLTE

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  DEC 16, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  DEC 3, 1911 to DEC 16, 1911

That I last saw him/her alive on (date):  DEC 15, 1911

And that death occurred on the date stated above at (time AM/PM):  3 AM

THE CAUSE OF DEATH was as follows:  PNEUMONIA - LOBAR

 

(Duration)   Years:            Months:            Days:  16

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  A.A. SIMMONS

Date:  DEC 16, 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:  DEC 17, 191

20.   UNDERTAKER:  M. HAMMON & SON

ADDRESS:  CLOVERPORT
************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************