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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. Pct:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  130

Primary Registration District No:  5301

File No.  21283.

Registered No: 

1.       FULL NAME:  DEHAVEN, CLINT MOORMAN

PERSONAL AND STATISTICAL PARTICULARS

2.       SEX:     FEMALE

3.       COLOR OR RACE:  BLACK

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

5.       DATE OF BIRTH: 11 / 2 / 1882

6.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  22 YRS

7.       OCCUPATION (a.) Trade, profession or particular kind of work:  

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

8.       BIRTHPLACE:  DEARFIELD, OHIO CO, KY

9.       NAME OF FATHER:  [STEP FATHER]  NARA PEYTON MOORMAN

10.   BIRTHPLACE OF FATHER:  DON’T KNOW

11.   MAIDEN NAME OF MOTHER:  MOLLIE MOORMAN

12.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  

(Address)  

14.   Filed  SEP -, 1911

REGISTAR:  W. B. LENNON

MEDICAL CERTIFICATE OF DEATH

15.   DATE OF DEATH:  9 / 20 / 1911

16.   I HEREBY CERTIFY, That I attended deceased from (date):  SEP 7, 1911 to SEP 20, 1911

That I last saw him/her alive on (date):  SEP 7, 1911

And that death occurred on the date stated above at (time AM/PM):  8 PM

THE CAUSE OF DEATH was as follows:  PULMONARY TUBERCULOSIS

 

(Duration)   Years:            Months:      6      Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  JOHN E. KINCHELOE

Date:  SEP 20, 1911

Address:  HARDINSBURG

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:  MC QUADY, KY

DATE OF BURIAL:  SEP 21, 1911

19.   UNDERTAKER:  E.F. LYONS

ADDRESS:  MC QUADY

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Copyright.  All rights reserved.
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