Date:  
Cert: #
Place of Death: County: Knott      City or Town: 
Length of stay (in this place): (blank)
Full Name of Hospital or Institution:  (blank)
Usual Residence of Deceased: State: Ky.     County: Knott
City or Town:                   Residence on a Farm?:   Yes
Street Address: (blank)     Residence inside City Limits?:  No
Full Name:   
Date of Death:   
Sex, Color or Race, Marital Status:  
Date of Birth:  
Age:   years,  months,  days
Usual Occupation:  (blank)
Kind of Industry or business: (blank)
Birthplace:  
Father's Name:   
Mother's Maiden Name:   
Was deceased ever in armed forces: (blank)
Social Security No.: (blank)
Informant:   
Disease or condition directly leading to death:  
Interval between onset and death:  (blank)
Due to: (blank)
Other significant conditions: (blank)
Date of Operation: (blank)
Major findings of operation: (blank)
Autopsy: No
Accident, suicide, or homicide: (blank)
Describe how injury occurred:  (blank)
Time of injury:  (blank)
Injury occurred at work: (blank)
Place of injury: (blank)
City, Town or Location, County, State: (blank)
I hereby certify that I attended deceased from (blank) to (blank), that I last saw the deceased alive on (blank), and that death occurred at (blank), from the causes and on the date stated above.
Date signed:  
Address:  
Signature:  
Burial, Cremation or Removal: Burial
Date:  
Name of Cemetery or Crematory:  
Location:  
Date received by local registrar:  
Registrar's Signature: Myrtle Slone
Funeral director & address:  
Transcribed by Debbie Tamborski, 25 April 2012