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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.: Big Spring KY

Inc Town: Glean Big Spring KY

City:

No.

St.

Ward

Registration District No.: 5314

Primary Registration District No: 14

File No. 22685

Registered No: 4

2.       FULL NAME: Virra Thompson Haynes

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: Married

6.       DATE OF BIRTH: June 17, 1881

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 30 yrs 3 mos 9 ds.

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

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

9.       BIRTHPLACE: Kentucky

10.   NAME OF FATHER: J. T. Thompson

11.   BIRTHPLACE OF FATHER: Kentucky

12.   MAIDEN NAME OF MOTHER: Caroline Gardener

13.   BIRTHPLACE OF MOTHER: Kentucky

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

(Informant) Jas A Haynes

(Address)  Big Spring KY

15.   Filed 9-27-1911

REGISTAR: J L Morris

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Sept. 26, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date): Feb 22, 1910 to Sept 26, 1911

That I last saw him/her alive on (date): Sept 26, 1911

And that death occurred on the date stated above at (time AM/PM): 7 PM

THE CAUSE OF DEATH was as follows: Pulmonary Tuberculosis

 

(Duration)

Years: 1

Months: 7

Days: 4

Signed (M.D.): C.B. Witt

Date: Sept 27, 1911

Address: Big Spring, 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 Baptist Church Cemetery

DATE OF BURIAL: Sept 27, 1911

20.   UNDERTAKER: R O Pennick

ADDRESS: Custer KY

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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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