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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.:  MOOK

Inc Town:  

City:  MOOK

No.  

St.  

Ward:  

Registration District No.:  5317

Primary Registration District No:  

File No.  5638

Registered No:  7

2.        FULL NAME:  BUTLER, ORA

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  FEMALE

4.        COLOR OR RACE:  WHITE

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

6.        DATE OF BIRTH:  SEP 17, 1911

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  0 / 5 / 14

8.        OCCUPATION (a.) Trade, profession or particular kind of work:  AT HOME

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

9.        BIRTHPLACE:  LOCUST HILL

10.     NAME OF FATHER:  MURRAY BUTLER

11.     BIRTHPLACE OF FATHER:  MOOK, BRECKINRIDGE, KY

12.     MAIDEN NAME OF MOTHER:  EMELINE BUTLER

13.     BIRTHPLACE OF MOTHER:  LOCUST HILL

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

(Informant)  WILBUR BUTLER

(Address)  LOCUST HILL

15.     Filed  MAR 4, 1911

REGISTAR:  V.G. GOODMAN

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  MAR 3, 1911

17.     I HEREBY CERTIFY, That I attended deceased from (date):  FEB 25, 1911 to MAR 3, 1911

That I last saw him/her alive on (date):  MAR 3, 1911

And that death occurred on the date stated above at (time AM/PM):  9 PM

THE CAUSE OF DEATH was as follows:  DOUBLE PNEUMONIA AND IMFLAMATION OF THE BOWELS

 

(Duration)   Years:            Months:            Days:  8

Contributory:  INFLAMATION OF THE BOWELS

 

(Duration)   Years:            Months:            Days:  2

Signed (M.D.):  J.A. SANDBACH

Date:  MAR 4, 1911

Address:  GARFIELD

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:  TURPEN GRAVEYARD

DATE OF BURIAL:  MAR 4, 1911

20.     UNDERTAKER:  HENRY COLLINWORTH

ADDRESS:  MOOK

 

TRANSCRIBER’S NOTE:  


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