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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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PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  WEBSTER

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  8820

Registered No:  

1.       FULL NAME:  HUMPHREY, MRS JANE

PERSONAL AND STATICAL PARTICULARS

2.       SEX:  FEMALE

3.       COLOR OR RACE:  WHITE

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

5.       DATE OF BIRTH:  APRIL 11, 1841

6.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  70 YRS

7.       OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWIFE

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

8.       BIRTHPLACE:  MEADE CO, KY

9.       NAME OF FATHER:  CISSELL

10.   BIRTHPLACE OF FATHER:  

11.   MAIDEN NAME OF MOTHER:  JUNE CURL

12.   BIRTHPLACE OF MOTHER:  

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

(Informant)  C.E. ARNOLD

(Address)  WEBSTER, KY

14.   Filed  APR 9, 1911

REGISTAR:  HOLLIS DRANE

MEDICAL CERTIFICATE OF DEATH

15.   DATE OF DEATH:  APRIL 8, 1911

16.   I HEREBY CERTIFY, That I attended deceased from (date):  MAR 29, 1911 to APR 8, 1911

That I last saw him/her alive on (date):  APR 8, 1911

And that death occurred on the date stated above at (time AM/PM):  9 PM

THE CAUSE OF DEATH was as follows:  TUBERCULOSIS CAUSED FROM LAYSISS

 

(Duration)   Years:    3        Months:            Days:  

Contributory:  LAYSISS

 

(Duration)   Years:  3          Months:            Days:  

Signed (M.D.):  T.J. HENDRICK

Date:  APR 9, 1911

Address:  WEBSTER, KY

17.   LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)

At place of death (yr, mo, da.):  0 / 1 / 0

In the State (yr, mo, da):  70 YRS

Where was disease contracted,  if not at place of death?  

Former or usual residence:  

18.   PLACE OF BURIAL OR REMOVAL:  WEBSTER

DATE OF BURIAL:  APR 10, 1911

19.   UNDERTAKER:  E.V. WRIGHT

ADDRESS:  BRANDENBURG


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************