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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:  2nd

Registration District No.:  130

Primary Registration District No:  5302

File No.  17183

Registered No: 47 

2.        FULL NAME:  BEAUCHAMP, MINNIE

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  FEMALE

4.        COLOR OR RACE:  BLACK

5.        SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE

6.        DATE OF BIRTH:  FEB 12, 1898

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  13 / 5 / 7

8.        OCCUPATION (a.) Trade, profession or particular kind of work:  

(b.)  General nature of industry business or establishment which employed:  

9.        BIRTHPLACE:  UNITED STATES

10.     NAME OF FATHER:  JOHN BEAUCHAMP

11.     BIRTHPLACE OF FATHER:  UNITED STATES

12.     MAIDEN NAME OF MOTHER:  DELIA DUNCAN

13.     BIRTHPLACE OF MOTHER:  UNITED STATES

14.     THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  EBENEZER G. DUNCAN 

(Address)  MCQUADY

15.     Filed  JUL 21, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH: JUL 20, 1911

17.     I HEREBY CERTIFY, That I attended deceased from (date):  MAY 24, 1911 to JUN 12, 1911

That I last saw him/her alive on (date):  JUN 12, 1911

And that death occurred on the date stated above at (time AM/PM):  4 PM

THE CAUSE OF DEATH was as follows:  TUBERCULAR PERITONITIS

 

(Duration)   Years:            Months:      2     Days:  15

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  W.H. LUCAS

Date:  JUL 21, 1911

Address:  MCQUADY

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:  MCQUADY

DATE OF BURIAL:  JUL 21, 1911

20.     UNDERTAKER:  E.F. LYONDS

ADDRESS:  MCQUADY

 

TRANSCRIBER’S NOTE:  


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Copyright.  All rights reserved.
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