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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. Pol.:  

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  5635

Registered No5312:  

2.       FULL NAME:  JOLLY, LYDIA A.

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  F

4.       COLOR OR RACE:  W

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

6.       DATE OF BIRTH:  OCT 10, 1857

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  54 / 0 / 0

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

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

9.       BIRTHPLACE:  HARDINSBURG

10.   NAME OF FATHER:  JOHN HENSELEY

11.   BIRTHPLACE OF FATHER:  KY

12.   MAIDEN NAME OF MOTHER:  NANNIE HENSLEY

13.   BIRTHPLACE OF MOTHER:  HARDINSBURG

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

(Informant)  R. MORRIS JOLLY

(Address)  IRVINGTON, KY

15.   Filed  3/31/1911

REGISTAR:  D.W. HENRY

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  3-23-1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  3-16-1911 to 3-23-1911

That I last saw him/her alive on (date):  3-22-1911

And that death occurred on the date stated above at (time AM/PM):  10:45 AM

THE CAUSE OF DEATH was as follows:  LA GRIPPE – COUGH WITH PNEUMONIA

 

(Duration)   Years:            Months:            Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

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

Date:  

Address:  

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:  IRVINGTON

DATE OF BURIAL:  3-25-1911

20.   UNDERTAKER:  MARSHALL

ADDRESS:  IRVINGTON


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