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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Union Star
Inc Town:  Raymond
City:  
No.  
St.  
Ward:  
Registration District No.:  5309
Primary Registration District No:  
File No.  6367
Registered No:  
2. FULL NAME:  Mary Hazel Knott
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  Aug 17, 1912
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  7 months, 1 day
8. OCCUPATION (a.) Trade, profession or particular kind of work:  none
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge County, KY
10. NAME OF FATHER:  Renfro Knott
11. BIRTHPLACE OF FATHER:  Breckinridge County, KY
12. MAIDEN NAME OF MOTHER:  Lizzie Hardesty
13. BIRTHPLACE OF MOTHER:  Meade County, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  [unreadable] Knott
(Address)  Raymond, KY
15. Filed  3 - 18, 1913
REGISTAR:  Hollis Drake
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  March 18, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  March 17 to March 17, 1913
That I last saw him/her alive on (date):  March 17, 1913
And that death occurred on the date stated above at (time AM/PM):  8 PM
THE CAUSE OF DEATH was as follows:  Pneumonia
 
(Duration)   Years:            Months:            Days:  2
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Dr. T. H. Hardesty
Date:  3 - 19 - 1913
Address:  Paynesville, KY
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:  Raymond, Ky
DATE OF BURIAL:  3 -19 - 1913
20. UNDERTAKER:  G. T. Marshall & Son
ADDRESS:  [blank]
 

ADDITIONAL COMMENTS/NOTES: This child isn't listed in either Breckinridge County Cemeteries, Volume 1 or 2.
 
 
 

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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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