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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:  2
Registration District No.:  130
Primary Registration District No:  5302
File No.  19017
Registered No:  114
2.	FULL NAME:  Berry, Ray
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  female
4.	COLOR OR RACE:  white
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6.	DATE OF BIRTH:  Feby 18, 1912
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  6 mos 3 ds.
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KY
10.	NAME OF FATHER:  John E. Berry
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  Bettie L. Carwile
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Alex Carwile
(Address)  Kingswood, KY
15.	Filed  W. B. Lennon
REGISTAR:  
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  August 21, 1912
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  7 A.M.
THE CAUSE OF DEATH was as follows:  
Cholera infantum
(Duration)   Years:            Months:            Days:  2
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. E. Matthews
Date:  Aug 22, 1912
Address:  Westview, 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:  Kingswood Cemetery
DATE OF BURIAL:  Aug. 22, 1912
20.	UNDERTAKER:  Peter Sheeran Bro. & Co. 
ADDRESS:  Kirk, KY

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Copyright.  All rights reserved.
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