1. PLACE OF DEATH County: Breckinridge Vot. Pol.: 12 Inc Town: Irvington, Ky City: No. St. Ward Registration District No.: Primary Registration District No: 5312 File No. 27 (16550 stamped above) Registered No: 5312 1. FULL NAME: Georgia Jones PERSONAL AND STATICAL PARTICULARS 2. SEX: F 3. COLOR OR RACE: black 4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married 5. DATE OF BIRTH: March 29, 1892 6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 20yrs2mos7ds 7. OCCUPATION (a.) Trade, profession or particular kind of work: housewife (b.) General nature of industry business or establishment which employed: 8. BIRTHPLACE: Ky 9. NAME OF FATHER: Ben Haynes 10. BIRTHPLACE OF FATHER: Ky 11. MAIDEN NAME OF MOTHER: Mattie Robertson 12. BIRTHPLACE OF MOTHER: Ky 13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Frank Jones (Address) Irvington, Ky 14. Filed July 8, 1912 REGISTAR: D.W. Henry MEDICAL CERTIFICATE OF DEATH 15. DATE OF DEATH: 7-7-1912 16. I HEREBY CERTIFY, That I attended deceased from (date): June10, 1911 to June 6, 1912 That I last saw him/her alive on (date): June 6, 1912 And that death occurred on the date stated above at (time AM/PM): THE CAUSE OF DEATH was as follows: Chronic Parenchymatoma Nephritis (Duration) Years: 1 Months: Days: Contributory: Child Birth Signed (M.D.): A.A. Baxter Date: 6/10/1912 Address: Guston, Ky 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: Irvington, Ky DATE OF BURIAL: 7-8-1912 19. UNDERTAKER: GT Marshall & son ADDRESS: Irvington, Ky