1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Rock Vale
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5320
File No.  27058
Registered No:  5320
2. FULL NAME:  Claud Thomas White
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  
6. DATE OF BIRTH:  Feb. 22, 1900
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  12 yrs  9 mos  8 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer’s Son
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ohio Co., Ky
10. NAME OF FATHER:  W. Dempsey White
11. BIRTHPLACE OF FATHER:  Ohio Co., Ky
12. MAIDEN NAME OF MOTHER:  Dorice T. Johnson
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Olla Basham
(Address)  
15. Filed  12/10, 1912
REGISTAR:  J. D. McDonogh
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Nov. 30, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Nov. 30, 1912 to Nov. 30, 1912
That I last saw him/her alive on (date):  Nov. 30, 1912
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  gun shot wound due to an accidental discharge of a gun

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Hedden D. Godsey, M.D.
Date:  Nov. 30, 1912
Address:  Fordsville, Ky R2
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:  Whittinghill Cemetery
DATE OF BURIAL:  Dec. 1, 1912
20. UNDERTAKER:  L. D. Orr
ADDRESS:  Jones Ky