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1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.:
Inc Town: Mooleyville
City:
No. 5310
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 14268
Registered No:
1. FULL NAME: Emma Gertrude Burch
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: November 8th 1898
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 13yrs7mos6ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: at home
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Ky. Breck. Co.
9. NAME OF FATHER: E.E. Burch
10. BIRTHPLACE OF FATHER: Ky. Meade Co.
11. MAIDEN NAME OF MOTHER: E.G. Wheatley
12. BIRTHPLACE OF MOTHER: Ky. Breck. Co.
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Lee Burch
(Address) Mooleyville, Ky
14. Filed June 14, 1911
REGISTAR: Jennie Cunningham
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: June 14, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): March 1, 1911 to June 9, 1911
That I last saw him/her alive on (date): June 9, 1911
And that death occurred on the date stated above at (time AM/PM): 6
THE CAUSE OF DEATH was as follows:
Sarcoma of the kidney
(Duration)
Years:
Months: 6
Days:
Signed (M.D.): D.S. Sphire
Date: June 14, 1911
Address: Mooleyville
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: St Theresa
DATE OF BURIAL: June 15, 1911
19. UNDERTAKER: J.E. Ball
ADDRESS: Andyville, Ky

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