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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.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5302
File No.  17456
Registered No:  [blank]
2. FULL NAME:  Susan Alexander
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  black
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6. DATE OF BIRTH:  Jan 23, 1843
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  71 years, 6 months, 17 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:  Kentucky
10. NAME OF FATHER:  Wyat Haynes
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:   Charni [??]  Haynes
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Winchester Alexander
(Address)  Hardinsburg, Ky
15. Filed  July 7, 1914
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 6, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date): July 6 to July 6, 1914
That I last saw him/her alive on (date):  July 6, 1914
And that death occurred on the date stated above at (time AM/PM):  6:30 AM
THE CAUSE OF DEATH was as follows:  General [unreadable]
 
(Duration)   Years:            Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  John Kincheloe
Date:  
Address:  Hardinsburg
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:  Colored Cemetery
DATE OF BURIAL:  July 7, 1914
20. UNDERTAKER:  B. F. Beard & Co.
ADDRESS:  Hardinsburg, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
(3131) written in by hand above the file number
 


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