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1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hardinsburg
Inc Town:
City:
No.
St.
Ward
Registration District No.: 130
Primary Registration District No: 5301
File No.25002
Registered No: 65
1. FULL NAME: Charlotte Duval
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Feb 13, 1873
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 38yrs8mos17ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:  house keeper
8. BIRTHPLACE: Kentucky
9. NAME OF FATHER: John H Campbell
10. BIRTHPLACE OF FATHER: Kentucky
11. MAIDEN NAME OF MOTHER: Nannie Ealy (?)
12. BIRTHPLACE OF MOTHER: Kentucky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Wm Duval
(Address) Hardinsburg, Ky
14. Filed Oct 30, 1911
REGISTAR: W.B. Lennon
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: October 30, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Nov 7, 1910 to Oct 30, 1911
That I last saw him/her alive on (date): Oct 30, 1911
And that death occurred on the date stated above at (time AM/PM): 8 < >
THE CAUSE OF DEATH was as follows:
Carcinoma of breast and uterus
(Duration)
Years: 2
Months:
Days:
Signed (M.D.): Jno. E. Kincheloe
Date: Oct 30, 1911
Address: Hardinsburg, 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: Overton Ky
DATE OF BURIAL: Nov 1, 1911
19. UNDERTAKER: B.F. Beard & Co
ADDRESS: Hardinsburg, Ky









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Copyright.  All rights reserved.
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