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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:  22
Vot. Pol.:  IRVINGTON
Inc Town:  
City:   
No.  
St.  
Ward:   
Registration District No.:  5312
Primary Registration District No:   
File No.  31026
Registered No:  5312 
2. FULL NAME:  MARY CAMPBELL
PERSONAL AND STATICAL PARTICULARS
3. SEX:  FEMALE
4. COLOR OR RACE:  NEGRO
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  NOV 20, 1895
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  18  YR 1 MO  5  DA     MIN
8. OCCUPATION (a.) Trade, profession or particular kind of work:   
(b.)  General nature of industry business or establishment which employed:   
9. BIRTHPLACE:  IRVINGTON
10. NAME OF FATHER:  GOFF CAMPBELL
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  SELIA JONES
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  ROMI STAPLES
(Address)  IRVINGTON KY
15. Filed  DEC 26,  1913
REGISTAR:  D W HENRY  BY SALLIE BEAUCHAMP
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  DEC 25,   1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  MARCH 1913 TO DEC 25,, 1913
That I last saw him/her alive on (date):  HER ALIVE DEC 24  1913
And that death occurred on the date stated above at (time AM/PM):  8P 
THE CAUSE OF DEATH was as follows:    PULMONARY TUBERCULARIS
 
(Duration)   Years:       10     Months:            Days:  
Contributory:   SENILITY
 
(Duration)   Years:            Months:            Days:   
Signed (M.D.):  C H NEVITT
Date:   DEC 26, 1913
Address:  IRVINGTON, 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:  BABPTIST HILL
DATE OF BURIAL:  DEC 27,, 1913
20. UNDERTAKER:  G T. MARSHALL & SON
ADDRESS:  Irvington, KY
 

ADDITIONAL COMMENTS/NOTES:

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Copyright.  All rights reserved.
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