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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.:

Primary Registration District No:

File No. 24672

Registered No:

2.       FULL NAME: Mrs. Annie Horseley

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: October 4 1879

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 31 yrs 11 mos 27 da

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

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

9.       BIRTHPLACE: Breckinridge Co KY

10.   NAME OF FATHER: Joseph A. Lyon

11.   BIRTHPLACE OF FATHER: Breckinridge Co KY

12.   MAIDEN NAME OF MOTHER: Margret Ann Priest

13.   BIRTHPLACE OF MOTHER: Breckinridge Co KY

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

(Informant) Joel Allgood

(Address) Garfield

15.   Filed: Oct 1, 1911

REGISTAR: R O Pennick

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: September 29 

17.   I HEREBY CERTIFY, That I attended deceased from (date): July 29, 1911 to Sept 18, 1911

That I last saw him/her alive on (date): Sept 10, 1911

And that death occurred on the date stated above at (time AM/PM): 6 AM

THE CAUSE OF DEATH was as follows: Tuberculosis of lungs

 

(Duration)

Years:

Months:

Days:

Signed (M.D.): J W Meador

Date: Sept 29, 1911

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 Garfield Cemetery

DATE OF BURIAL: Oct 1, 1911

20.   UNDERTAK ER: R.O. Pennick

ADDRESS: Custer KY


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