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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.: Ball Town KY

Inc Town: 

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 27059

Registered No: 4

2.       FULL NAME: Bertha Burdett

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single

6.       DATE OF BIRTH: Jan 29, 1882

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 20 yrs 9 mos 13 da

8.       OCCUPATION (a.) Trade, profession or particular kind of work: Assisted in house keeping

(b.)  General nature of industry business or establishment which employed:

9.       BIRTHPLACE: KY

10.   NAME OF FATHER: Gideon Burdett

11.   BIRTHPLACE OF FATHER: KY

12.   MAIDEN NAME OF MOTHER: Mary Jane Mattingly

13.   BIRTHPLACE OF MOTHER: KY

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant) Yid Burdett

(Address) Mattingly KY

15.   Filed Nov 16, 1912

REGISTAR: Fred Frank

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Nov 12, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Aug 17, 1912 to Oct 21, 1912

That I last saw him/her alive on (date): Oct 21, 1912

And that death occurred on the date stated above at (time AM/PM): 1 PM

THE CAUSE OF DEATH was as follows: Tuberculosis of Lungs

 

(Duration)

Years:

Months: 7

Days:

Signed (M.D.): P E Dempster

Date: Nov 13, 1912

Address: Glen Dean 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 St Marys of Woods

DATE OF BURIAL: Nov 13, 1912

20.   UNDERTAKER: Chas Hammond

ADDRESS: Cloverport KY


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