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1.    PLACE OF DEATH

County:  Breckinridge

Vot. Pol.:  Hardinsburg

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5302

Primary Registration District No:  130

File No.  27035

Registered No:  131

2.    FULL NAME:  Claud Shaw

PERSONAL AND STATICAL PARTICULARS

3.    SEX:  male    

4.    COLOR OR RACE:  white

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

6.    DATE OF BIRTH:  Sept 1, 1911

7.    AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1y, 2m, 5days

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

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

9.    BIRTHPLACE:  Louisville, Jefferson County, KY

10.   NAME OF FATHER:  Claud Shaw

11.   BIRTHPLACE OF FATHER:  Rymon, Breck Co., KY

12.   MAIDEN NAME OF MOTHER:  Nancy J. Sutton

13.   BIRTHPLACE OF MOTHER:  Hardinsburg, Breckinridge County, KY

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

(Informant)  Tommy Sutton

(Address)  Garfield, KY

15.   Filed  Nov. 10, 1912

REGISTAR:  W. B. Lennon

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  Nov. 5, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Oct 31, to Nov 5, 1912

That I last saw him/her alive on (date):  Nov. 5, 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:  11

Contributory:  Whooping Cough

 

(Duration)   Years:            Months:  2          Days:  7

Signed (M.D.):  J. A. Sandbach

Date:  Nov 5, 1912

Address:  Garfield

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:  [Blank]

DATE OF BURIAL:  Nov 6, 1912

20.   UNDERTAKER:  I. B. Richardson

ADDRESS:  Garfield

 
 

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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