1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  Yes
City:  Hardinsburg
No.  
St.  
Ward:  3
Registration District No.:  5303
Primary Registration District No:  130
File No.  11574
Registered No:  26
2. FULL NAME:  Jim Scott
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  Colored
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  June 1, 1888
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  23 yrs  7 mos
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge County
10. NAME OF FATHER:  Hallian Scott
11. BIRTHPLACE OF FATHER:  Hardinsburg, Ky
12. MAIDEN NAME OF MOTHER:  Sarah Hendrick
13. BIRTHPLACE OF MOTHER:  Maysland
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Jack Hendrick
(Address)  Cannonsdale
15. Filed  May 1, 1911
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  May first, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  April 29, 1911 to May 1, 1911
That I last saw him/her alive on (date):  April 29, 1911
And that death occurred on the date stated above at (time AM/PM):  11 a.m.
THE CAUSE OF DEATH was as follows:  Pulmonary Tuberculosis

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. A. Lex M.D.
Date:  5/1, 1911
Address:  Hardinsburg
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:  Collored Cemetery
DATE OF BURIAL:  May 2, 1911
20. UNDERTAKER:  J. T. Hoben
ADDRESS:  Hardinsburg, Ky
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