1. PLACE OF DEATH
County:  Breck
Vot. Pol.:  
Inc Town:  Irvington, Ky
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5312
File No.  27666
Registered No:  16
2. FULL NAME:  Nash Thomas
PERSONAL AND STATICAL PARTICULARS
3. SEX:  M
4. COLOR OR RACE:  W
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Nov. 14, 1871
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  40 yrs  15 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Laborer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ky
10. NAME OF FATHER:  F. M. Thomas
11. BIRTHPLACE OF FATHER:  Ky
12. MAIDEN NAME OF MOTHER:  
13. BIRTHPLACE OF MOTHER:  Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Thos Thomas
(Address)  Irvington, Ky
15. Filed  Nov. 19, 1911
REGISTAR:  D. W. Henry
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Nov. 29, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Nov. 10, 1911 to Nov. 26, 1911
That I last saw him/her alive on (date):  Nov. 26, 1911
And that death occurred on the date stated above at (time AM/PM):  12:00 a.m.
THE CAUSE OF DEATH was as follows:  Tuberculosis

(Duration)   Years:  2          Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  A. A. Baxter, M.D.
Date:  Nov. 29, 1911
Address:  Guston, 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:  Rosetta, Ky
DATE OF BURIAL:  Nov. 29, 1911
20. UNDERTAKER:  G. T. Marshall & Son
ADDRESS:  Irvington, Ky

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