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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.:  5306

Inc Town:  

City:  CLOVERPORT

No.  

St.  

Ward:  

Registration District No.:  131

Primary Registration District No:  3065

File No.  2955

Registered No:  3

2.        FULL NAME:  BEAVIN, MRS. CLARA ELDER

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  FEMALE

4.        COLOR OR RACE:  WHITE

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

6.        DATE OF BIRTH:  JUL 9, 1880

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  30 / 7 / 5

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

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

9.        BIRTHPLACE:  BRECKINRIDGE

10.     NAME OF FATHER:  THOMAS ELDER

11.     BIRTHPLACE OF FATHER:  BRECKINRIDGE

12.     MAIDEN NAME OF MOTHER:  ROSA WALKER

13.     BIRTHPLACE OF MOTHER:  BRECKINRIDGE

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

(Informant)  ALLEN ELDER

(Address)  LOUISVILLE, KY

15.     Filed  FEB 15, 1911

REGISTAR:  J.C. NOLTE

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  FEB 14, 1911

17.     I HEREBY CERTIFY, That I attended deceased from (date):  JAN 14, 1911 to FEB 14, 1911

That I last saw him/her alive on (date):  FEB 14, 1911

And that death occurred on the date stated above at (time AM/PM):  3 PM

THE CAUSE OF DEATH was as follows:  LARYNGEAL TUBERCULOSIS

 

(Duration)   Years:            Months:            Days:  45

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  C.R. LIGHTFOOT

Date:  FEB 15, 1911

Address:  CLOVERPORT

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:  HARDINSBURG

DATE OF BURIAL:  FEB 15, 1911

20.     UNDERTAKER:  M. HAMMON & SONS

ADDRESS:  CLOVERPORT

 

TRANSCRIBER’S NOTE:  

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