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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.: Mooleyville
Inc Town:
City:
No. 1d
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 6  (has 20133 written above)
Registered No: 5310
1. FULL NAME: Elizabeth W. Burch
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: widow
5. DATE OF BIRTH: July 13, 1836
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 75yrs 1mo3ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed: none
8. BIRTHPLACE: Kentucky
9. NAME OF FATHER: George Frymire
10. BIRTHPLACE OF FATHER: Kentucky
11. MAIDEN NAME OF MOTHER: Rachel Wimp (?)
12. BIRTHPLACE OF MOTHER: Kentucky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Mrs. L.H. Bosley
(Address) Chenault, Ky
14. Filed Aug 18, 1911
REGISTAR: Jennie Cumming
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Aug 17, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): July 26, 1911 to July 26, 1911
That I last saw him/her alive on (date): July 26, 1911
And that death occurred on the date stated above at (time AM/PM): 6:45 am
THE CAUSE OF DEATH was as follows:
Cancer of the liver
(Duration) 
Years:
Months: 6
Days:
Signed (M.D.): D.S.Sphire
Date: Aug 17, 1911
Address: Mooleyville, 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: Gethsemane
DATE OF BURIAL: Aug 18, 1911
19. UNDERTAKER: J.F. Jarboe
ADDRESS: Chenault, Ky

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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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