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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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1.       PLACE OF DEATH

County: Breckinridge

Vot. Pol.: Rock Vale

Inc Town: 

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 21647

Registered No: 5320

2.       FULL NAME: Stillborn

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: 

6.       DATE OF BIRTH: 

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

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

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

9.       BIRTHPLACE: KY

10.   NAME OF FATHER: Alphonso Willaby

11.   BIRTHPLACE OF FATHER: KY

12.   MAIDEN NAME OF MOTHER: Joann Lacefield

13.   BIRTHPLACE OF MOTHER: KY

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

(Informant) Alphonso Willaby

(Address) Vanzant KY

15.   Filed Sept 6, 1912

REGISTAR: J D McDonogh

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Sept 4, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):

That I last saw him/her alive on (date):

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

THE CAUSE OF DEATH was as follows: Stillbirth

  

(Duration)

Years:

Months:

Days:

Signed (M.D.): P E Dempster

Date: Sept 5, 1912

Address: Glen Dean 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 Robertson Burial Ground

DATE OF BURIAL: Sept 5, 1912

20.   UNDERTAKER: None

ADDRESS:


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Copyright.  All rights reserved.
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