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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.:  ROCKVALE
Inc Town:  
City:  
No.  
St.  
Ward:
Registration District No.:  5324
Primary Registration District No:  
File No.  30158
Registered No:  
2.	FULL NAME:  SMITH, JASPER
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  1896
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  18 YR
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: SCOTT SMITH  
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  FLORENCE HOLLAND
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  WAVIR SANDERS
(Address)  TAR FORK, KY
15.	Filed  
REGISTRAR:  
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  OCT 23, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  OCT 10, 1914
That I last saw him/her alive on (date):  OCT 22, 1914
And that death occurred on the date stated above at (time AM/PM):  11 AM
THE CAUSE OF DEATH was as follows:  ACUTE OTITIS MEDIA

(Duration)   Years:            Months:           Days:  13
Contributory:  PNEUMONIA

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  C. DEWEESE
Date:  OCT. 23, 1914
Address:  FORDSVILLE, 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:  DUANE GRAVEYARD
DATE OF BURIAL:  OCT 24, 1914
20.	UNDERTAKER:  O. T. COBB
ADDRESS:  FORDSVILLE, KY


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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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