1. PLACE OF DEATH
County: BRECKINRIDTGE
Vot. Pol.: 5307
Inc Town: CLOVERPORT
City:
No.
St.
Ward:
Registration District No.: 131
Primary Registration District No: 2065
File No. 125
Registered No:
2. FULL NAME: ALLEN, JAMES H.
PERSONAL AND STATICAL PARTICULARS
3. SEX: MALE
4. COLOR OR RACE: WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE
6. DATE OF BIRTH: JAN 20, 1907
7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 6 / 10 / 3
8. OCCUPATION (a.) Trade, profession or particular kind of work: NONE
(b.) General nature of industry business or establishment which employed:
9. BIRTHPLACE: KENTUCKY
10. NAME OF FATHER: WM. B. ALLEN
11. BIRTHPLACE OF FATHER: KENTUKCY
12. MAIDEN NAME OF MOTHER: JENNIE WITT
13. BIRTHPLACE OF MOTHER: KENTUCKY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) JOE ALLEN
(Address) CLOVERPORT
15. Filed OCT 25, 1913
REGISTAR: J.C. NOLTE
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: OCT 24, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date): OCT 15, 1913 to OCT 24, 1913
That I last saw him/her alive on (date): OCT 24, 1913
And that death occurred on the date stated above at (time AM/PM): 3:30 PM
THE CAUSE OF DEATH was as follows: LOBAR PNEUMONIA

(Duration) Years: Months: Days: 9
Contributory:

(Duration) Years: Months: Days:
Signed (M.D.): E.C. McDANIEL
Date: OCT 25, 1913
Address: CLOVERPORT
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: CLOVERPORT
DATE OF BURIAL: OCT 25, 1913
20. UNDERTAKER: M. HAMMON & SONS
ADDRESS: CLOVERPORT