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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:  of Breckinridge
Vot. Pol.:  Rockvale
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  132
Primary Registration District No:  
File No.  22337
Registered No:  
2.  FULL NAME:  Willaim H. Zachery
PERSONAL AND STATICAL PARTICULARS
3.  SEX:  Male
4.  COLOR OR RACE:  White
5.  SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widowed
6.  DATE OF BIRTH:  June 20, 1843
7.  AGE  (yr. mo. da) (If less than 1 day, hours or min?):  68 yrs, 4 days
8.  OCCUPATION (a.) Trade, profession or particular kind of work:  Laborer
(b.)  General nature of industry business or establishment which employed:  
9.  BIRTHPLACE:  No one knows
10.  NAME OF FATHER:  Bartlet Zachery
11.  BIRTHPLACE OF FATHER:  Not known
12.  MAIDEN NAME OF MOTHER:  Raymer, Beckie
13.  BIRTHPLACE OF MOTHER:  Not known
14.  THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. W. Moore Sr.
(Address)  Vanzant, Ky
15.  Filed  July 5, 1911
REGISTAR:  E. L. Robertson
MEDICAL CERTIFICATE OF DEATH
16.  DATE OF DEATH:  July 4th, 1911
17.  I HEREBY CERTIFY, That I attended deceased from (date):  July 2, 1911 to July 3, 1911
That I last saw him alive on (date):  July 3, 1911
And that death occurred on the date stated above at (time AM/PM):  8 AM
THE CAUSE OF DEATH was as follows:  uremie coma

(Duration)   Years:  July 2-July 4          Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  M. O. Robertson
Date:  July 4, 1911
Address:  Glendeane, 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:  Not known
DATE OF BURIAL:  7, 5, 1911
20.  UNDERTAKER:  W. G. Moorman
ADDRESS:  Glendeane

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Copyright.  All rights reserved.
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