Date:  
Cert:  
Place of Death: County: Knott     City or Town:
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky.      County:
City or Town:
Full Name:
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status:
Husband or Wife of:
Age of husband or wife if alive:
Birth date of deceased:
Age: years, months, days
Birthplace:
Occupation:
Industry or business: (blank)
Father Name:
Father Birthplace:
Mother Maiden Name:
Mother Birthplace:
Informant:
Burial Place:
Date:
Signature of funeral director:
Date received by local registrar:
Registrar's Signature:
Date of Death:
I hereby certify that I attended deceased from (blank) to (blank), that I last saw him alive on (blank), and that death occurred on the date stated above at (blank)
Immediate cause of death:
Duration: (blank)
Due to: (blank)
Major findings of operations: (blank)
Accident, suicide, or homicide: (blank)
Date of occurrence: (blank)
Where did injury occur: (blank)
While at work: (blank)
Means of injury: (blank)
Signature & Address: 
Date signed:
Transcribed by Debbie Tamborski, 07 November 2010