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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:  5302
File No.  17457
Registered No:  
2.	FULL NAME:  FLOYD, ADA KATHRYNE
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  OCT 9, 1903
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  10 / 9 / 21
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  STUDENT
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  O.E. FLOYD
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  KATE DENTON
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  O.E. FLOYD
(Address)  KINGSWOOD, KY
15.	Filed  AUG 1, 1914
REGISTAR:  W.B. LENNON
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: JUL 30, 1914 
17.	I HEREBY CERTIFY, That I attended deceased from (date):  JUL 25, 1914 to JUL 30, 1914
That I last saw him/her alive on (date):  JUL 30, 1914
And that death occurred on the date stated above at (time AM/PM):  1 PM
THE CAUSE OF DEATH was as follows:  APPENDECITIS WITH OPERATION
(Duration)   Years:            Months:            Days:    5
Contributory:  GENERAL INFECTION ESPECIALLY OF CENTRAL NERVOUS SYSTEM
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J.L. LIGHTFOOT
Date:  JUL 30, 1914
Address:  KINGSWOOD
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:  KINGSWOOD CEM
DATE OF BURIAL:  AUG 1, 1914
20.	UNDERTAKER:  ROBERT WEATHERFORD
ADDRESS:  HARNED


ADDITIONAL COMMENTS/NOTES:




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