1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  McDaniels
Inc Town:  
City:  McDaniels
No.  
St.  
Ward:  
Registration District No.:  5318
Primary Registration District No:  
File No.  14280
Registered No:  18
2. FULL NAME:  Kirby Edward Smith
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  June 16, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  Infant
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Madrid, Ky
10. NAME OF FATHER:  Meyer Smith
11. BIRTHPLACE OF FATHER:  Milwood
12. MAIDEN NAME OF MOTHER:  Ina Tucker
13. BIRTHPLACE OF MOTHER:  Madrid, Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Valentine Eskridge
(Address)  Madrid, Ky
15. Filed  Jun 16, 1911
REGISTAR:  M. M. Jarboe
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  June 16, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 16, 1911
That I last saw him/her alive on (date):  June 17, 1911
And that death occurred on the date stated above at (time AM/PM):  1 a.m.
THE CAUSE OF DEATH was as follows:  Premature Labor

(Duration)   Years:            Months:            Days:  
Contributory:  asphyxiation from cord

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. C. Tucker, M.D.
Date:  June 17, 1911
Address:  McDaniels, 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:  
DATE OF BURIAL:  
20. UNDERTAKER:  
ADDRESS:  

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