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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5301

Primary Registration District No:  130

File No.  17176

Registered No: 39

2.       FULL NAME:  VESSELS, PAUL MONROE

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     MALE

4.       COLOR OR RACE:  WHITE

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE

6.       DATE OF BIRTH: APR 24, 1911

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  0 / 3 / 12

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  

(b.)  General nature of industry business or establishment which employed:  

9.       BIRTHPLACE:  UNITED STATES

10.   NAME OF FATHER:  ROBERT PEMBROSE VESSELS

11.   BIRTHPLACE OF FATHER:  UNITED STATES

12.   MAIDEN NAME OF MOTHER:  ANNA AGNES BROWN

13.   BIRTHPLACE OF MOTHER:  UNITED STATES

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  AMBROSE VESSELS, RFD #1

(Address)  HARDINSBURG

15.   Filed  JUL 6, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  JUL 5, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  JUL 1, 1911 to JUL 5, 1911

That I last saw him/her alive on (date):  JUL 3, 1911

And that death occurred on the date stated above at (time AM/PM):  9 PM

THE CAUSE OF DEATH was as follows:  CHOLERA INFANTUM

 

(Duration)   Years:            Months:            Days:  5

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  W.H. LUCAS

Date:  6 JUL 1911

Address:  MCQUADY

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:  ST ROMUALDS

DATE OF BURIAL:  JUL 6, 1911

20.   UNDERTAKER:  PETE SHEERAN

ADDRESS:  KIRK



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Copyright.  All rights reserved.
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