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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Bewleyville
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5315
Primary Registration District No:  
File No.  14272
Registered No:  111
2.	FULL NAME:  Legrand, Margie Johnson
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  female
4.	COLOR OR RACE:  white
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widow
6.	DATE OF BIRTH:  Oct. 28, 1862
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  49 yrs  4 mos.  26 ds.  
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  House Keeper
(b.)  General nature of industry business or establishment which employed:  House work
9.	BIRTHPLACE:  KY ? 
10.	NAME OF FATHER:  Daniel Johnson
11.	BIRTHPLACE OF FATHER:  
12.	MAIDEN NAME OF MOTHER:  Lucinda 
13.	BIRTHPLACE OF MOTHER:  
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Sihoy ??  Johnson
(Address)  
15.	Filed  June 3, 1911  
REGISTAR:  R. O. Penick
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  June 2, 1911
17.	I HEREBY CERTIFY, That I attended deceased from (date):  May 21, 1911 to June 2, 1911
That I last saw him/her alive on (date):  May 31, 1911
And that death occurred on the date stated above at (time AM/PM):  1.a.m.
THE CAUSE OF DEATH was as follows:  
Measles
(Duration)   Years:            Months:            Days:  17
Contributory:  
Albumimrsia
(Duration)   Years:            Months:            Days:  6
Signed (M.D.):  J. A. Sandbach
Date:  June 2, 1911
Address:  Garfield
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:  Garfield, KY
DATE OF BURIAL:  June 3, 1911
20.	UNDERTAKER:  I. B. Richardson
ADDRESS:  Garfield, KY

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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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