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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.        PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  HARDINSBURG

Inc Town:  HARDINSBURG

City:  

No.  

St.  

Ward:  3rd

Registration District No.:  130

Primary Registration District No:  5305

File No.  14258

Registered No: 35 

2.        FULL NAME:  BEAVEN, ZEULAH COX

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  FEMALE

4.        COLOR OR RACE:  BLACK

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

6.        DATE OF BIRTH:  OCT 4, 1877

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  33 / 8 / 25

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

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

9.        BIRTHPLACE:  KENTUCKY

10.     NAME OF FATHER:  JAMES COX

11.     BIRTHPLACE OF FATHER:  KENTUCKY

12.     MAIDEN NAME OF MOTHER:  ROBERT ANNE PARKER

13.     BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  JESSIE BEAVEN

(Address)  HARDINSBURG

15.     Filed  JUN 29, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH: JUN 29, 1911 

17.     I HEREBY CERTIFY, That I attended deceased from (date):  JUN 28, 1911 to JUN 29, 1911

That I last saw him/her alive on (date):  JUN 28, 1911

And that death occurred on the date stated above at time AM/PM):  6:15 AM

THE CAUSE OF DEATH was as follows:  PULMONARY TUBERCULOSIS

 

(Duration)   Years:            Months:     3       Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  JOHN E. KINCHELOE

Date:  JUN  29, 1911

Address:  HARDINSBURG

18.     LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)

At place of death (yr, mo, da.):   4 YRS, 0 MONTHS, 7 DAYS

In the State (yr, mo, da):  EVANSVILLE, IN

Where was disease contracted,  if not at place of death?  EVANSVILLE, IN

Former or usual residence:  

19.     PLACE OF BURIAL OR REMOVAL:  HARDINSBURG CEM

DATE OF BURIAL:  JUN 29, 1911

20.     UNDERTAKER:  J.T. HOBEN

ADDRESS:  HARDINSBURG

 

TRANSCRIBERS NOTE:  FATHER’S SURNAME/MAIDEN NAME MAY BE BROWN OR BEAN
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