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1.    PLACE OF DEATH

County:  Breckinridge

Vot. Pol.:  Glen Dean, KY

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5319

Primary Registration District No:  

File No.  16153

Registered No:  

2.    FULL NAME:  Charlie Sermon

PERSONAL AND STATICAL PARTICULARS

3.    SEX:  male

4.    COLOR OR RACE:  white

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

6.    DATE OF BIRTH:  March 21, 1908

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

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

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

9.    BIRTHPLACE:  Illinois

10.   NAME OF FATHER:  Ed Sermon

11.   BIRTHPLACE OF FATHER:  KY

12.   MAIDEN NAME OF MOTHER:  Luth Ellison

13.   BIRTHPLACE OF MOTHER:  KY

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

(Informant)  John Sermon

(Address)  Glen Dean, KY

15.   Filed  March 26, 1912

REGISTAR:  E. L. Robertson

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  March 25, 1912 'DELAY' stamped on form

17.   I HEREBY CERTIFY, That I attended deceased from (date): Mar 23, to Mar 25, 1912 

That I last saw him/her alive on (date):  Mar 25, 1912

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

THE CAUSE OF DEATH was as follows:  Broncho Pneumonia

 

(Duration)   Years:            Months:            Days:  2

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  P. E. Dempster

Date:  March 25, 1912

Address: Glen Dean, 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:  Carwile Burial Ground

DATE OF BURIAL:  March 26, 1912

20.   UNDERTAKER:  W. R. Pierce

ADDRESS:  Glen Dean

 
 

ADDITIONAL COMMENTS/NOTES:

 

 

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File contributed for use in USGenWeb Archives by:

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

http://www.usgwarchives.net

 

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