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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:  2

Registration District No.:  

Primary Registration District No:  

File No.  11573

Registered No: 28

2.       FULL NAME:  WALES, DAVIS S.A.

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     MALE

4.       COLOR OR RACE:  BLACK

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

6.       DATE OF BIRTH: JUN 11, 1909

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 / 11 /  0

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

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  THRUSTON WALES

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  LILLIE DEHAVEN

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  ROBERT WEATHERFORD

(Address)  HARNED

15.   Filed  MAY 12, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  MAY 11, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  APR 25, 1911 to MAY 11, 1911

That I last saw him/her alive on (date):  MAY 9, 1911

And that death occurred on the date stated above at (time AM/PM):  9-10 AM

THE CAUSE OF DEATH was as follows:  MENINGEAL TUBERCULOSIS

 

(Duration)   Years:            Months:      2      Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  JOHN E. KINCHELOR

Date:  MAY 11, 1911

Address:  HARDINSBURG

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:  WALES CEMETERY

DATE OF BURIAL:  MAY 12, 1911

20.   UNDERTAKER:  ROBERT WEATHERFORD

ADDRESS:  HARNED


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