1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Webster
Inc Town: Webster
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5311
File No. 3325
Registered No:
1. FULL NAME: Carie Bell Johnson
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: black
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: 8/15/1910
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 1yr6mos4ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Breckinridge Co
9. NAME OF FATHER: Henry Johnson
10. BIRTHPLACE OF FATHER: Saratoga (?) Miss
11. MAIDEN NAME OF MOTHER: Kate Haynes
12. BIRTHPLACE OF MOTHER: Garfield, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Horace Bridwell
(Address) Webster, Ky
14. Filed 2/19/1912
REGISTAR: H. Drane
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Feb 19, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Feb 19, 1912 to Feb 19, 1912
That I last saw him/her alive on (date): Feb 19, 1912
And that death occurred on the date stated above at (time AM/PM): 5:30 AM
THE CAUSE OF DEATH was as follows:
Croupe
(Duration)
Years:
Months:
Days:
Signed (M.D.): T.J. Hendrick
Date: Feb 19, 1912
Address: Webster
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Garfield, Ky
DATE OF BURIAL: 2/20/1912
19. UNDERTAKER: Henry Johnson
ADDRESS: