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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:  Yes
City:  Irvington, Ky
No.  
St.  
Ward:  
Registration District No.:  5312
Primary Registration District No:  
File No.  259
Registered No:  
2.  FULL NAME:  John Young
PERSONAL AND STATICAL PARTICULARS
3.  SEX:  M
4.  COLOR OR RACE:  Blk
5.  SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6.  DATE OF BIRTH:  Don't know, 1904
7.  AGE  (yr. mo. da) (If less than 1 day, hours or min?):  6 yrs
8.  OCCUPATION (a.) Trade, profession or particular kind of work:  Child
(b.)  General nature of industry business or establishment which employed:  
9.  BIRTHPLACE:  Ky
10.  NAME OF FATHER:  Don't know
11.  BIRTHPLACE OF FATHER:  
12.  MAIDEN NAME OF MOTHER:  Ida Young
13.  BIRTHPLACE OF MOTHER:  Ky
14.  THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Stan Young
(Address)  Irvington, Ky
15.  Filed  Jan 27, 1911
REGISTAR:  D. W. Henry
MEDICAL CERTIFICATE OF DEATH
16.  DATE OF DEATH:  Jan 11, 1911
17.  I HEREBY CERTIFY, That I attended deceased from (date):  Jan 5, 1911 to Jan 10, 1911
That I last saw him/her alive on (date):  Jan 10, 1911
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  Spinal Meningitis

(Duration)   Years:            Months:            Days:  {illegible}
Contributory:  Cold

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  L. B. Moorman
Date:  1-4,1911
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:  Irvington, Ky
DATE OF BURIAL:  Jan 11, 1911
20.  UNDERTAKER:  G. T. MARSHALL & Son
ADDRESS:  Irvington, Ky

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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************