1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hudson
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5316
Primary Registration District No:  
File No.  17301
Registered No:  14
2. FULL NAME:  Elbridge Smallwood
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  
6. DATE OF BIRTH:  Apr. 25, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  2 mos  13 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ky
10. NAME OF FATHER:  Jessie Smallwood
11. BIRTHPLACE OF FATHER:  Ky  Hardin Co
12. MAIDEN NAME OF MOTHER:  Norma May Tanner
13. BIRTHPLACE OF MOTHER:  Hardin Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Jessie Smallwood
(Address)  Constantine, Ky
15. Filed  7/15, 1911
REGISTAR:  J. H. Comer
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 8, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 8, 1911 to July 8, 1911
That I last saw him/her alive on (date):  July 8, 1911
And that death occurred on the date stated above at (time AM/PM):  2 p.m.
THE CAUSE OF DEATH was as follows:  innutrition

(Duration)   Years:            Months:            Days:  about 30
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  H. C. Stone
Date:  July 8, 1911
Address:  Constantine
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:  Family Grave yard
DATE OF BURIAL:  7/9, 1911
20. UNDERTAKER:  Wm. Smallwood
ADDRESS:  Constantine, Ky

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