************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: 5307 Inc Town: CLOVERPORT City: No. St. 3RD Ward: Registration District No.: Primary Registration District No: File No. 20125 Registered No: 29 2. FULL NAME: JONES, KITTIE OWENS PERSONAL AND STATICAL PARTICULARS 3. SEX: FEMALE 4. COLOR OR RACE: COLORED 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: WIDOWED 6. DATE OF BIRTH: MAY 15, 1862 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 49 / 2 / 20 8. OCCUPATION (a.) Trade, profession or particular kind of work: HOUSEKEEPER (b.) General nature of industry business or establishment which employed: GENERAL HOUSEWORK 9. BIRTHPLACE: KENTUCKY 10. NAME OF FATHER: SAMUEL OWENS 11. BIRTHPLACE OF FATHER: KENTUCKY 12. MAIDEN NAME OF MOTHER: MARY MOORMAN 13. BIRTHPLACE OF MOTHER: KENTUCKY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) ARTHUR HARRIS (Address) 1619 W. CHESTNUT, LOUISVILLE, KY 15. Filed AUG 5, 1911 REGISTAR: J.C. NOLTE MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: AUG 4, 1911 17. I HEREBY CERTIFY, That I attended deceased from (date): JUN 26, 1911 to AUG 4, 1911 That I last saw him/her alive on (date): AUG 4, 1911 And that death occurred on the date stated above at (time AM/PM): 4 PM THE CAUSE OF DEATH was as follows: CANCER OF STOMACHE AND WOMB (Duration) Years: Months: Days: Contributory: INDIGESTION (Duration) Years: Months: Days: DON’T KNOW Signed (M.D.): JAS T. OWEN Date: AUG 5, 1911 Address: CLOVERPORT 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: CLOVERPORT DATE OF BURIAL: M. HAMMAN & SON 20. UNDERTAKER: CLOVERPORT ADDRESS: ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************