************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ 1. PLACE OF DEATH County: Breckenridge Vot. Pol.: Custer Inc Town: City: No. St. Ward: Registration District No.: 5815 Primary Registration District No: 15 File No. 17906 Registered No: 55 2. FULL NAME: Barbara Gray PERSONAL AND STATICAL PARTICULARS 3. SEX: female 4. COLOR OR RACE: white 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single 6. DATE OF BIRTH: July 6, 1913 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 20 days 8. OCCUPATION (a.) Trade, profession or particular kind of work: infant (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Breckenridge County 10. NAME OF FATHER: John Gray 11. BIRTHPLACE OF FATHER: Hardin Co., KY 12. MAIDEN NAME OF MOTHER: Ellen Auberry 13. BIRTHPLACE OF MOTHER: Hardin Co., KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) H. Bruner (Address) Custer 15. Filed July 26, 1913 REGISTAR: J. T. Mitcham MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: July 26, 1913 17. I HEREBY CERTIFY, That I attended deceased from (date): That I last saw him/her alive on (date): July 6, 1913 And that death occurred on the date stated above at (time AM/PM): 1 PM THE CAUSE OF DEATH was as follows: Whooping Cough (Duration) Years: Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): j. W. Meador Date: July 26, 1913 Address: Custer, 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: Bill Smallwood, BG DATE OF BURIAL: July 27, 1913 20. UNDERTAKER: James Pile ADDRESS: Custer, Ky ADDITIONAL COMMENTS/NOTES: ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************