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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.:  GLEN DEAN, KY
Inc Town:  
City:  
No.  
St.  
Ward:
Registration District No.:  19
Primary Registration District No:  5319
File No.  3513
Registered No:  2
2.	FULL NAME:  SMITH, JIM HENRY, JR.
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  FEB. 14, 1914
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  24 HR
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:  JIM HENRY SMITH, SR.
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  ANNIE STAPLES
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  JAMES DEAN
(Address)  GLEN DEAN, KY
15.	Filed  FEB. 18, 1914
REGISTRAR:  MOLLY DEMPSTER
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  FEB. 15, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  3:30 AM
THE CAUSE OF DEATH was as follows:  FOUND DEAD IN BED

(Duration)   Years:            Months:           Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P. E. DEMPSTER
Date:  FEB. 15, 1914
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 CEMETERY
DATE OF BURIAL:  FEB. 15, 1914
20.	UNDERTAKER:  JIM DEAN
ADDRESS:  GLEN DEAN, KY



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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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