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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:  

Inc Town:  

City:  IRVINGTON

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  5312

File No.  27049

Registered No: 5312

2.       FULL NAME:  JARRETT, MARY DURBAN

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  APR 1845

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  67 YRS

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

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

9.       BIRTHPLACE:  BRECKINRIDGE CO

10.   NAME OF FATHER:  JOHN DURBAN

11.   BIRTHPLACE OF FATHER:  VIRGINIA

12.   MAIDEN NAME OF MOTHER:  DON’T KNOW

13.   BIRTHPLACE OF MOTHER:  DON’T KNOW

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

(Informant)  JAMES JARRETT, SON

(Address)  

15.   Filed  DEC 4, 1912

REGISTAR:  D.W. HENRY

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: NOV 20, 1912 

17.   I HEREBY CERTIFY, That I attended deceased from (date):  NOV 17, 1912 to NOV 20, 1912

That I last saw him/her alive on (date):  NOV 20, 1912

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

THE CAUSE OF DEATH was as follows:  PNEUMONIA  1 WK.

 

(Duration)   Years:            Months:            Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  L.B. MOORMAN

Date:  

Address:  IRVINGTON

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:  

DATE OF BURIAL:  

20.   UNDERTAKER:  

ADDRESS:  

 



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