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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. Pct:  ROCKVALE

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5320

Primary Registration District No:  

File No.  16157

Registered No: 

2.       FULL NAME:  HUFF, BERDIE PAYNE

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE

4.       COLOR OR RACE:  WHJITE

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

6.       DATE OF BIRTH: MAR 15, 1889

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  23 / 2 / 25

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

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

9.       BIRTHPLACE:  OHIO CO, KY

10.   NAME OF FATHER:  HENRY PAYNE

11.   BIRTHPLACE OF FATHER:  OHIO CO, KY

12.   MAIDEN NAME OF MOTHER:  JOSEPHINE BIVEN

13.   BIRTHPLACE OF MOTHER:  MEADE CO, KY

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

(Informant)  JOHN BIVEN

(Address)  GLEN DEAN

15.   Filed  MAR 21, 1912

REGISTAR:  E.L. ROBERTSON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  MAR 25, 1912  [DELAYED]

17.   I HEREBY CERTIFY, That I attended deceased from (date):  JUL 22, 1911 to MAR 25, 1912

That I last saw him/her alive on (date):  MAR 25, 1912

And that death occurred on the date stated above at (time AM/PM):  11 AM

THE CAUSE OF DEATH was as follows:  TUBERCULOSIS OF THE LUNGS

 

(Duration)   Years:     1       Months:    8        Days:    25 

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  R.Y. DEMPSTER

Date:  MAR 25, 1912

Address:  GLEN DEAN, 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:  ST MARY’S OF THE WOODS  [DAVIESS CO]

DATE OF BURIAL: MAR 26, 1912 

20.   UNDERTAKER:  

ADDRESS:  

 



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Copyright.  All rights reserved.
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