1. PLACE OF DEATH County: Breckinridge Vot. Pol.: 12 Inc Town: City: Irvington No. St. Ward: Registration District No.: 5312 Primary Registration District No: 25 File No. 11901 Registered No: 2. FULL NAME: Cleaver, Carrie PERSONAL AND STATICAL PARTICULARS 3. SEX: Female 4. COLOR OR RACE: Colored 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single 6. DATE OF BIRTH: July 1, 1900 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 11 yr 5 mo 18 da 8. OCCUPATION (a.) Trade, profession or particular kind of work: School (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Irvington 10. NAME OF FATHER: Levy Cleaver 11. BIRTHPLACE OF FATHER: Breckinridge Co., KY 12. MAIDEN NAME OF MOTHER: Janie Young 13. BIRTHPLACE OF MOTHER: Breckinridge Co., KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Jessie Cleaver (Address) Irvington, KY 15. Filed May ?, 1912 REGISTRAR: D. W. Henry MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: May 15, 1912 17. I HEREBY CERTIFY, That I attended deceased from (date): Apr 1912 That I last saw him/her alive on (date): May 1, 1912 And that death occurred on the date stated above at (time AM/PM): THE CAUSE OF DEATH was as follows: Pulmonary tuberculosis (Duration) Years: 1 Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): L. B. Moorman Date: May 16, 1912 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: Irvington, KY DATE OF BURIAL: May 16, 1912 20. UNDERTAKER: G. T. Marshall & Son ADDRESS: Irvington, KY ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************