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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. Pol.:  Bewleyville
Inc Town:
City:
No.
St.
Ward
Registration District No.:  5313
Primary Registration District No:
File No.:  17197
Registered No:  4
2. FULL NAME:  Evenlyn Hardaway
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  1836, 11, 1
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  74 yrs, 11 mos, 1 day
8. OCCUPATION:
(a.) Trade, profession or particular kind of work:  Housewife
(b.)  General nature of industry business or establishment which employed:
9. BIRTHPLACE:  Meade Co.
10. NAME OF FATHER:  Buckes Stith
11. BIRTHPLACE OF FATHER:  Meade Co.
12. MAIDEN NAME OF MOTHER:  Lusdasillce Stith
13. BIRTHPLACE OF MOTHER:  Meade Co.
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant):  E. P. Hardaway
(Address):  Irvington
15. Filed
REGISTAR:
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  July 2, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date)::  June 1911 to July 1, 1911
That I last saw him/her alive on (date):  July 1, 1911
And that death occurred on the date stated above at (time AM/PM):  6 am
THE CAUSE OF DEATH was as follows:  Dysentery

(Duration)
Years:
Months: 1
Days:
Signed (M.D.):  J. M. Walker
Date:
Address:  Irvingotn, 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:  Home Place
DATE OF BURIAL:  July 3, 1911
20. UNDERTAKER:
ADDRESS:

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Copyright.  All rights reserved.
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