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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.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5301
File No.  567
Registered No:  
2.	FULL NAME:  SMITH, STOY B.
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  APRIL 27, 1911
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 YR 8 MO 5 DA
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:  BOWMAN D. SMITH
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  OLLIE LASLIE
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  W.  P. LASLEY
(Address)  CLOVERPORT, KY
15.	Filed  JAN 2, 1913
REGISTRAR:  W. B. LENNON
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  JAN 2, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  NOV. 28, 1912
That I last saw him/her alive on (date):  NOV 28, 1912
And that death occurred on the date stated above at (time AM/PM):  5 AM
THE CAUSE OF DEATH was as follows:  TUBERCULOSIS

(Duration)   Years:     1       Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.): A. M. KINCHELOE
Date:  JAN. 2, 1913
Address:  HARDINSBURG, 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:  Moorman Cemetery #3
DATE OF BURIAL:  JAN 2, 1913
20.	UNDERTAKER:  (Unreadable)
ADDRESS:  KIRK, KY

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Copyright.  All rights reserved.
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