************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: 12 Inc Town: IRVINGTON City: No. St. Ward: Registration District No.: 5312 Primary Registration District No: File No. 66318 Registered No: 2. FULL NAME: WELCH, MANN PERSONAL AND STATICAL PARTICULARS 3. SEX: MALE 4. COLOR OR RACE: BLACK 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 6. DATE OF BIRTH: MAY 16, 1897 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 17 YR 3 MO 8. OCCUPATION (a.) Trade, profession or particular kind of work: RAILROADER (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: KY 10. NAME OF FATHER: JIM WELCH 11. BIRTHPLACE OF FATHER: KY 12. MAIDEN NAME OF MOTHER: MALIARIS POOL 13. BIRTHPLACE OF MOTHER: KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) MRS. MAT POOL (Address) IRVINGTON, KY 15. Filed AUG. 16, 1914 REGISTRAR: SUE C. JOLLY MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: AUG 16, 1914 17. I HEREBY CERTIFY, That I attended deceased from (date): AUG 26, 1912 That I last saw him/her alive on (date): AUG 16, 1914 And that death occurred on the date stated above at (time AM/PM): 7 AM THE CAUSE OF DEATH was as follows: INJURIES RECEIVED FROM A MOVING TRAIN (Duration) Years: Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): S. P. PARKS Date: AUG 16, 1912 (SIC) Address: IRVINGTON, 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: CLOVERPORT DATE OF BURIAL: AUG 17 1914 20. UNDERTAKER: G. T. MARSHALL ADDRESS: IRVINGTON, KY ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************