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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Glen Dean
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5319
Primary Registration District No:  19
File No.  17909
Registered No:  
2. FULL NAME:  James Franklin Smith
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  Sept 2, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 year, 7 months, 17 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  nothing
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge County, Ky
10. NAME OF FATHER:  Wm. M. Smith
11. BIRTHPLACE OF FATHER:  Handcock County, Ky
12. MAIDEN NAME OF MOTHER:  Sarah V. Weidman
13. BIRTHPLACE OF MOTHER:  Grayson County, Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Wm. M. Smith
(Address)  Glen Dean, Ky
15. Filed  July 19, 1913
REGISTAR:  Mrs. Molly Dempster
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 19, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 30 to July 18, 1913
That I last saw him/her alive on (date):  July 18, 1913
And that death occurred on the date stated above at (time AM/PM):  11 PM
THE CAUSE OF DEATH was as follows:  Inflammation of Stomach
 
(Duration)   Years:            Months:            Days:  18
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P.E. Dempster
Date:  July 19, 1913
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:  McQuady, Ky
DATE OF BURIAL:  July 19, 1913
20. UNDERTAKER:  Mr. Brickey
ADDRESS:  McQuady, Ky
 

ADDITIONAL COMMENTS/NOTES:
 


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