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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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PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  HARDINSBURG

Inc Town:  

City:  HARNED

No.  

St.  

Ward:  2

Registration District No.:  30

Primary Registration District No:  5302

File No.  28118

Registered No: 49

1.       FULL NAME:  WALES, RAYMOND ALEXANDER

PERSONAL AND STATISTICAL PARTICULARS

2.       SEX:     MALE

3.       COLOR OR RACE:  BLACK

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

5.       DATE OF BIRTH: MAY 27, 1911

6.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  0 / 2 / 17

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

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

8.       BIRTHPLACE:  KENTUCKY

9.       NAME OF FATHER:  THRUSTON WALES

10.   BIRTHPLACE OF FATHER:  KENTUCKY

11.   MAIDEN NAME OF MOTHER:  LILLIE DEHAVEN

12.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  CLARENCE BELT

(Address)  HARNED

14.   Filed  AUG 14, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

15.   DATE OF DEATH:  AUG 13, 1911

16.   I HEREBY CERTIFY, That I attended deceased from (date):  AUG 12, 1911 to AUG 13, 1911

That I last saw him/her alive on (date):  AUG 12, 1911

And that death occurred on the date stated above at time AM/PM):  6 AM

THE CAUSE OF DEATH was as follows:  JUANITION

 

(Duration)   Years:            Months:       2     Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

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

Date:  AUG 13, 1911

Address:  HARDINSBURG

17.   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:  

18.   PLACE OF BURIAL OR REMOVAL:  WALES CEMETERY

DATE OF BURIAL:  AUG 13, 1911

19.   UNDERTAKER:  ROBT WEATHERFORD

ADDRESS:  HARNED


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Copyright.  All rights reserved.
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************************************************