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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.        

2.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  STEPHENSPORT

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5308

Primary Registration District No:  

File No.  16547

Registered No: 

3.       FULL NAME:  HORSLEY, JANE CANNON

PERSONAL AND STATISTICAL PARTICULARS

4.       SEX:     FEMALE

5.       COLOR OR RACE:  WHITE

6.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED

7.       DATE OF BIRTH: MAY 26, 1939

8.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  73 / 2 / 1

9.       OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEKEEPING

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

10.   BIRTHPLACE:  BRECKINRIDGE

11.   NAME OF FATHER:  ALBERT CANNON

12.   BIRTHPLACE OF FATHER:  KENTUCKY

13.   MAIDEN NAME OF MOTHER:  MARY ROBERTSON

14.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  AMOS WHITWORTH

(Address)  STEPHENSPORT

16.   Filed  JUL 20, 1912 

REGISTAR:  R.A. SHELLMAN

MEDICAL CERTIFICATE OF DEATH

17.   DATE OF DEATH:  JUL 191, 1912

18.   I HEREBY CERTIFY, That I attended deceased from (date):  JUL 13, 1912 to JUL 19, 1912

That I last saw him/her alive on (date):  JUL 19, 1912

And that death occurred on the date stated above at (time AM/PM):  8:30 PM

THE CAUSE OF DEATH was as follows:  FLUX

 

(Duration)   Years:            Months:            Days:  7

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  WILLIAM L. MILNER

Date:  7/-/1912

Address:  UNION STAR

19.   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:  

20.   PLACE OF BURIAL OR REMOVAL:  SAMPLE, KY

DATE OF BURIAL:  JUL 20, 1912

21.   UNDERTAKER:  W.J. SCHOPP

ADDRESS:  STEPHENSPORT

 





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