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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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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  
Inc Town:  CLOVERPORT, KY
City:  
No.  
St.  
Ward: 3
Registration District No.:  131
Primary Registration District No:  5307
File No.  14871
Registered No: 151 
2.	FULL NAME:  SIMS, CHARLES V.
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  WIDOWED
6.	DATE OF BIRTH:  AUGUST 5, 1858
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  55 YR 10 MO 10 DA
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  DARBY, INDIANA
10.	NAME OF FATHER:  RANDALL SIMS
11.	BIRTHPLACE OF FATHER:  SCOTLAND
12.	MAIDEN NAME OF MOTHER:  JULIA BIVEN
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  GUS BALLMAN
(Address)  CLOVERPORT, KY
15.	Filed  JUNE 16, 1914
REGISTRAR:  J. C. NOLTE
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: JUNE 15, 1914 
17.	I HEREBY CERTIFY, That I attended deceased from (date):  JUNE 15, 1912
That I last saw him/her alive on (date):  JUNE 15, 1914
And that death occurred on the date stated above at (time AM/PM):  11:00 AM
THE CAUSE OF DEATH was as follows:  PULMONARY TUBERCULOSIS

(Duration)   Years:     2       Months:           Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. C. MOORMAN
Date:  	JUNE 16, 1914
Address:  CLOVERPORT, 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:  BRECKINRIDGE CO., KY
DATE OF BURIAL:  JUNE 15, 1914
20.	UNDERTAKER:  M. HAMMAN & SON
ADDRESS:  CLOVERPORT, KY



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Copyright.  All rights reserved.
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