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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.:  MOOLEYVILLE, KY
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5310
File No.  592
Registered No:  
2.	FULL NAME:  BALL, MARY ADELINE
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  WIDOWED
6.	DATE OF BIRTH:  
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  ABOUT 67 YR
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWIFE
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  INDIANA
10.	NAME OF FATHER:  JIM SAM ELDER
11.	BIRTHPLACE OF FATHER:  INDIANA
12.	MAIDEN NAME OF MOTHER:  DOLLIE ANN JOHNSON
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  G. E. BALL
(Address)  MOOLEYVILLE, KY
15.	Filed  JAN 21, 1914
REGISTRAR:  J. D. CUNNINGHAM
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  JAN 21, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  JULY 3, 1913
That I last saw him/her alive on (date):  JAN 16, 1914
And that death occurred on the date stated above at (time AM/PM):  6 AM
THE CAUSE OF DEATH was as follows:  TUBERCULOSIS OF BOWELS

(Duration)   Years:            Months:     7      Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  D. S. SPIRE
Date:  JAN 21, 1914
Address:  MOOLEYVILLE, 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:  DERBY, INDIANA
DATE OF BURIAL:  JAN 22, 1914
20.	UNDERTAKER:  VICTOR GREEN
ADDRESS:  



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