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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.: Mook
Inc Town:
City:
No. 5317
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 25016
Registered No: 5317
1. FULL NAME: Beatrice Butler
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: Oct 11, 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 1day
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Ky
9. NAME OF FATHER: Forest Butler
10. BIRTHPLACE OF FATHER: Ky
11. MAIDEN NAME OF MOTHER: Lydia Leslie
12. BIRTHPLACE OF MOTHER: Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Jas O Leslie
(Address) Mook, Ky
14. Filed Oct 12, 1911
REGISTAR: V.E. Fordman
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Oct 12, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Oct 11, 1911 to Oct 11, 1911
That I last saw him/her alive on (date): Oct 11, 1911
And that death occurred on the date stated above at (time AM/PM): 2 AM
THE CAUSE OF DEATH was as follows:
Premature Birth
(Duration)
Years:
Months:
Days: 1
Signed (M.D.): J.E. Matthews
Date:
Address: Westview, 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: Butler grave
DATE OF BURIAL:
19. UNDERTAKER: Henry Collinsworth
ADDRESS:

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Copyright.  All rights reserved.
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