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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.: 12

Inc Town: Irvington

City: Irvington KY

No. 

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 29816

Registered No: 6912

2.       FULL NAME: Leroy Wilson

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:

6.       DATE OF BIRTH: January 18, 1912

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

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

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

9.       BIRTHPLACE: Irvington KY

10.   NAME OF FATHER: Luther Wilson

11.   BIRTHPLACE OF FATHER: Hardinsburg KY

12.   MAIDEN NAME OF MOTHER: Sally Brown

13.   BIRTHPLACE OF MOTHER: Hardinsburg KY

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

(Informant) Luther Wilson

(Address) Irvington KY

15.   Filed 12-20, 1912

REGISTAR: D W Henry

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Dec 19, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Dec 18, 1912 to Dec 19, 1912

That I last saw him/her alive on (date): Dec 19, 1912

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

THE CAUSE OF DEATH was as follows: Suppurative Atilis Mdia

 

(Duration)

Years:

Months: 11

Days: 1

Signed (M.D.): S P Parks

Date: Dec 20, 1912

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 Hardinsburg KY

DATE OF BURIAL: Dec 20, 1912

20.   UNDERTAKER: G T Marshal & Son

ADDRESS: Irvington KY


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Copyright.  All rights reserved.
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