PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: STEPHENSPORT Inc Town: City: No. St. Ward: Registration District No.: Primary Registration District No: File No. 20130 Registered No: 11 1. FULL NAME: MCCOY, ADDIE VANDERGRAFT PERSONAL AND STATICAL PARTICULARS 2. SEX: FEMALE 3. COLOR OR RACE: WHITE 4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: MARRIED 5. DATE OF BIRTH: JUN 30, 1860 6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 51 / 1 / 12 7. OCCUPATION (a.) Trade, profession or particular kind of work: HOUSEWIFE (b.) General nature of industry business or establishment which employed: 8. BIRTHPLACE: KENTUCKY 9. NAME OF FATHER: DAVID VANDERGRAFT 10. BIRTHPLACE OF FATHER: KENTUCKY 11. MAIDEN NAME OF MOTHER: CAROLINE KELENE 12. BIRTHPLACE OF MOTHER: KENTUCKY 13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) JOHN MCCOY (Address) SAMPLE, KY 14. Filed AUG 19, 1911 REGISTAR: R.R. SHELLMAN MEDICAL CERTIFICATE OF DEATH 15. DATE OF DEATH: AUG 12, 1911 16. I HEREBY CERTIFY, That I attended deceased from (date): That I last saw him/her alive on (date): SOMETIME IN JUNE And that death occurred on the date stated above at (time AM/PM): 3 AM THE CAUSE OF DEATH was as follows: FOUND DEAD IN BED (Duration) Years: Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): WILLIAM L. MILNER Date: 1/12/1911 Address: UNION STAR 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: FAMILY GRAVEYARD DATE OF BURIAL: AUG 13, 1911 19. UNDERTAKER: D.S. RICHARDSON ADDRESS: UNION STAR