1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  CUSTER
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  25014
Registered No:  
2. FULL NAME:  JONES, CATHERINE
PERSONAL AND STATICAL PARTICULARS
3. SEX:  FEMALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  OCT 21, 1908
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  3 / 0 / 1
8. OCCUPATION (a.) Trade, profession or particular kind of work:  INFANT
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  BRECKINRIDGE
10. NAME OF FATHER:  ALEXANDER JONES
11. BIRTHPLACE OF FATHER:  BRECKINRIDGE COUNTY
12. MAIDEN NAME OF MOTHER:  MARY BOARD
13. BIRTHPLACE OF MOTHER:  BRECKINRIDGE COUNTY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  L.J. BERNELL	
(Address)  CUSTER
15. Filed  OCT 23, 1911
REGISTAR:  R.O. PENICK
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  OCT 22, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  OCT 19, 1911 to OCT 22, 1911
That I last saw him/her alive on (date):  OCT 22, 1911
And that death occurred on the date stated above at (time AM/PM):  3 PM
THE CAUSE OF DEATH was as follows:  SCARLET FEVER

(Duration)   Years:            Months:            Days:  
Contributory:  DIPTHERIA

(Duration)   Years:            Months:            Days:  4
Signed (M.D.):  J.W. & R.W. MEADOR
Date:  OCT 23, 1911
Address:  CUSTER
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:  GOOD HOPE
DATE OF BURIAL:  OCT 23, 1911
20. UNDERTAKER:  R.O. PENICK
ADDRESS:  CUSTER