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DEATH
CERTIFICATE
ROBERT SMITH
Date 06 July 1919
Cert: 24337
Place of Death: Voting Precinct: Harveyton, First Creek,
Perry Co., Ky.
Full Name: Robert SMITH
Sex, Color or Race, Marital Status: Male, White, Married
Date of Birth: 08 August 1892
Age: 26 years, 11 months, 28 days
Occupation: Carpenter, Mining Plant
Birthplace: Knott Co., Kentucky
Name of Father: Andy SMITH
Birthplace Father: Kentucky
Maiden name of Mother: HUFF
Birthplace Mother: Kentucky
Informant/Address: Ballard SMITH
Filed: 06 July 1919
Registrar: (illegible)
Death Date: 06 July 1919
I hereby certify that I attended deceased from 05 July 1919, to
06 July 1919, that I last saw him alive on 06 July 1919, and
that death occurred, on the date stated above, at 7 a.m.
Cause of Death: Shock as a result of burns from an
accidental powder explosion in the Hazard Jellico Coal Co.
Mine
Duration: 10 hours
Contributory: (blank)
Signed/Address: W. E. Ray, M.D., 06 July 1919, Staub,
Ky.
Length of residence where disease contracted: (blank)
Former or usual residence: (blank)
Place of Burial or Removal: Knott Co., Ky.
Date of Burial: 08 July 1919
Undertaker/Address: G. W. Nickolson, Hazard, Ky.
Transcribed by Debbie Tamborski, 06 March 2010 |
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