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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.  PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Mook
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No:
File No. 24617
Registered No: 5317
2.       FULL NAME: Elza Hines
PERSONAL AND STATICAL PARTICULARS
3.       SEX: Male
4.       COLOR OR RACE: White
5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single
6.       DATE OF BIRTH: Aug 9, 1911
7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 1Day
8.       OCCUPATION (a.) Trade, profession or particular kind of work: 
(b.)  General nature of industry business or establishment which employed:
9.       BIRTHPLACE: Breck Co., KY
10.   NAME OF FATHER: Lawrence Hines
11.   BIRTHPLACE OF FATHER: KY
12.   MAIDEN NAME OF MOTHER: Mary Jane Davis
13.   BIRTHPLACE OF MOTHER: KY
14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Lawrence Hines
(Address) Mook KY
15.   Filed Aug 10, 1911
REGISTAR: V.E. Goodman
MEDICAL CERTIFICATE OF DEATH
16.   DATE OF DEATH: Aug 10, 1911
17.   I HEREBY CERTIFY, That I attended deceased from (date): Aug 9, 1911 to Aug 10, 1911
That I last saw him/her alive on (date): Aug 10, 1911
And that death occurred on the date stated above at (time AM/PM): 4 PM
THE CAUSE OF DEATH was as follows:Uresura

(Duration)
Years: 
Months:
Days: 1
Signed (M.D.): J.E. Matthews
Date: Aug 10, 1911
Address: Westview 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 R.E. Grave
DATE OF BURIAL: Aug 10, 1911
20.   UNDERTAKER: Geo Whitworth
ADDRESS: Mook KY

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Copyright.  All rights reserved.
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