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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.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  138
Primary Registration District No:  5302
File No.  17892
Registered No:  
2. FULL NAME:  Samuel Thomas Smith
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  [blank]
6. DATE OF BIRTH:  Dec 13, 1843
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  69 years, 7 months, 3 days
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:  Sam Smith
11. BIRTHPLACE OF FATHER:  Breckinridge County, Ky 
12. MAIDEN NAME OF MOTHER:  unknown
13. BIRTHPLACE OF MOTHER:  unknown
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  [blank]
(Address)  
15. Filed  July 17, 1913
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 16, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  Sept 14, 1912 to July 16, 1913
That I last saw him/her alive on (date):  July 9, 1913
And that death occurred on the date stated above at (time AM/PM):  2 PM
THE CAUSE OF DEATH was as follows:  Prostatic Hypertrophy
 
(Duration)   Years:   1         Months:     10       Days:  
Contributory:  Uremia
 
(Duration)   Years:            Months:            Days:  21
Signed (M.D.):  J. E. Mathews
Date:  July 16, 1913
Address:  West View, 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:  Scott County
DATE OF BURIAL:  July 17, 1913
20. UNDERTAKER:  J. T. Hoben
ADDRESS:  Hardinsburg, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 

 
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