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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Custer
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5315
File No.  17905
Registered No:  54
2. FULL NAME:  Etner Bennett
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  January 14, 1907
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  6 yrs  6 mos  9 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  At home
9. BIRTHPLACE:  Breckinridge
10. NAME OF FATHER:  Athel Bennett
11. BIRTHPLACE OF FATHER:  Breckinridge Co. Ky
12. MAIDEN NAME OF MOTHER:  Alice St. Clair
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Mrs. Venie Carter
(Address)  Custer, Ky
15. Filed  July 23, 1913
REGISTAR:  J. T. Mitcham
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 23, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 14, 1913 to July 21, 1913
That I last saw him/her alive on (date):  July 21, 1913
And that death occurred on the date stated above at (time AM/PM):  6 a.m.
THE CAUSE OF DEATH was as follows:  Chronic Endocarditis

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  S. W. Meador, M.D.
Date:  July 23, 1913
Address:  Custer, 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:  Bennett B. G.
DATE OF BURIAL:  July 23, 1913
20. UNDERTAKER:  Alf Taylor
ADDRESS:  Custer, Ky



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