1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Bewleyville
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5313
File No. 3328
Registered No: 62 (or 12)
1. FULL NAME: Sarah Jordan
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: Apr 30, 1845
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 66yrs9mos6ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: At home
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Breckinridge Co
9. NAME OF FATHER: Joel Jordan
10. BIRTHPLACE OF FATHER: Virginia
11. MAIDEN NAME OF MOTHER: Jane Jordan
12. BIRTHPLACE OF MOTHER: Virginia
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) CH Drury
(Address) Irvington
14. Filed Feb 7, 1912
REGISTAR: John Compton
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Feb 5, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Nov 15, 1911 to Feb 5, 1912
That I last saw him/her alive on (date): Feb 5, 1912
And that death occurred on the date stated above at (time AM/PM): 4PM
THE CAUSE OF DEATH was as follows:
Fracture of femur at the hip joint from a fall
(Duration)
Years:
Months:
Days:
Signed (M.D.): JM Walker
Date:  
Address: Irvington
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: Bewleyville, Ky
DATE OF BURIAL: Feb 6, 1912
19. UNDERTAKER: GT Marshall & son
ADDRESS: Irvington, Ky