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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.: Webster
Inc Town:
City:
No. 5311
St.
Ward
Registration District No.:
Primary Registration District No:
File No.  16783	
Registered No:
1. FULL NAME:  Sarah Alice Brown		
PERSONAL AND STATICAL PARTICULARS
2. SEX: Female
3. COLOR OR RACE: White
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Feb 14th 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 30yrs 4mos14da
7. OCCUPATION (a.) Trade, profession or particular kind of work: housewife
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Crawford Co, Ind
9. NAME OF FATHER: Wm Dane
10. BIRTHPLACE OF FATHER: Indiana
11. MAIDEN NAME OF MOTHER: EM Brown
12. BIRTHPLACE OF MOTHER: Indiana
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Robt Brown
(Address)  Webster, Ky.
14. Filed 6-8 1911
REGISTAR: H Drane
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: June 8, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): May 30, 1911 to June 8, 1911
That I last saw him/her alive on (date): June 8, 1911
And that death occurred on the date stated above at (time AM/PM):
THE CAUSE OF DEATH was as follows: Dysentery

(Duration)
Years:
Months:
Days: 8
Contributory: Confinement
Signed (M.D.): S.P. Parks
Date: June 8, 1911
Address: Irvington, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Webster, Ky.
DATE OF BURIAL: June 9, 1911
19. UNDERTAKER: G.T. Marshall
ADDRESS: Irvington

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Copyright.  All rights reserved.
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http://www.usgwarchives.net/ky/kyfiles.html
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