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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:  Breckinridge
Vot. Pol.:  Custer
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5315
Primary Registration District No:  
File No.  27308
Registered No:  81
2. FULL NAME:  Mrs. Ada A Adkisson
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white 
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6. DATE OF BIRTH:  April 12, 1890
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  24 years, 7 months, 5 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  at home
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge County, Ky
10. NAME OF FATHER:  Oskar P Lyons
11. BIRTHPLACE OF FATHER:  Breckinridge Co.,  Ky
12. MAIDEN NAME OF MOTHER:  Lucy Jane
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Richard Adkisson
(Address)  Hardinsburg, Ky
15. Filed  Nov 17, 1914
REGISTAR:  J. T. Mitcham
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Nov 17, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  Sept 15th to Nov 15th, 1914
That I last saw him/her alive on (date):  Nov 15, 1914
And that death occurred on the date stated above at (time AM/PM):  2 AM
THE CAUSE OF DEATH was as follows:  Tuberculosis of throat
 
(Duration)   Years:            Months:   10         Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. W. Meador
Date:  Nov 17, 1914
Address:  Custer, 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:  Gray Cemetery
DATE OF BURIAL:  Nov 18, 1914
20. UNDERTAKER:  J. S. Gray
ADDRESS:  Custer, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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