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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:  Breckinrdige Co
Vot. Pol.:  Stephensport
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  11677
Registered No:  5
2.  FULL NAME:  Samuel Wyttenbach
PERSONAL AND STATICAL PARTICULARS
3.  SEX:  Male
4.  COLOR OR RACE:  White
5.  SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Divorced
6.  DATE OF BIRTH:  July 19, 1837
7.  AGE  (yr. mo. da) (If less than 1 day, hours or min?):  73 yrs
8.  OCCUPATION (a.) Trade, profession or particular kind of work: School Teacher 
(b.)  General nature of industry business or establishment which employed:  No employment
9.  BIRTHPLACE:  Unknown
10.  NAME OF FATHER:  Christian Wyttenbach
11.  BIRTHPLACE OF FATHER:  Switzerland
12.  MAIDEN NAME OF MOTHER:  cannot state
13.  BIRTHPLACE OF MOTHER:  Switzerland
14.  THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Russell Wyttenbach
(Address)  Evansville, Ind
15.  Filed May 23, 1911
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16.  DATE OF DEATH:  May 22, 1911
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):  10 AM
THE CAUSE OF DEATH was as follows:  By being struck by train No 141 L. h. & St. Oh on Trestle 64 1/4

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Sam H. Dix J.P.B.C.
Date:  
Address:  
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:  Evansville, Ind
19.  PLACE OF BURIAL OR REMOVAL:  Evansville, Ind
DATE OF BURIAL:  May 23, 1911
20.  UNDERTAKER:  W. J. Schopp
ADDRESS:  Stephensport, Ky

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Copyright.  All rights reserved.
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