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1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Glen Dean, Ky
Inc Town: Glen Dean, Ky
City:
No. 5319 (the number 132 above)
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 30579
Registered No:
1. FULL NAME: Dosha Burnett
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: May 11, 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 7mos7ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Glen Dean, Ky
9. NAME OF FATHER: Wm Burnett
10. BIRTHPLACE OF FATHER: Ky
11. MAIDEN NAME OF MOTHER: Nancy Jane Powell
12. BIRTHPLACE OF MOTHER: Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) FM Powell
(Address) Glen Dean, Ky
14. Filed Dec 18, 1911
REGISTAR: E.L. Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Dec 18, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Nov 13, 1911 to Dec 17, 1911
That I last saw him/her alive on (date): Dec 17, 1911
And that death occurred on the date stated above at (time AM/PM): 3 am
THE CAUSE OF DEATH was as follows:
Acute bronchitis
(Duration)
Years:
Months: 1
Days: 4
Signed (M.D.): P.E. Dempster
Date:
Address: Glen Dean
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: Dunk (or Dink) Powell’s
DATE OF BURIAL: Dec 18, 1911
19. UNDERTAKER:  Tom Jones
ADDRESS: Glen Dean, Ky

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