1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Stephensport
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5308
File No.  17193
Registered No:  
2. FULL NAME:  Still birth Thompson
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  
6. DATE OF BIRTH:  July 28, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  Still birth
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:  J. W. Thompson
11. BIRTHPLACE OF FATHER:  Meade Co., Ky
12. MAIDEN NAME OF MOTHER:  Sopha Chism
13. BIRTHPLACE OF MOTHER:  Meade Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  
(Address)  
15. Filed  July 28, 1911
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  (Still birth)
17. I HEREBY CERTIFY, That I attended deceased from (date):  July 27, 1911 to July 28, 1911
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  2 a.m.
THE CAUSE OF DEATH was as follows:  Cause unknown (Still birth) don’t know

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  H. F. Litchfield, M.D.
Date:  July 28, 1911
Address:  Stephensport
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:  July 28, 1911
20. UNDERTAKER:  W. J. Schopp
ADDRESS:  

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