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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Stephensport
Inc Town:  Stephensport, KY
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  14342
Registered No:  
2. FULL NAME:  Mrs. Edna McCoy
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6. DATE OF BIRTH:  July 28, 1884
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  88 years
8. OCCUPATION (a.) Trade, profession or particular kind of work:  housewife
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Garfield, Breckenridge County, KY
10. NAME OF FATHER:  Charley Compton
11. BIRTHPLACE OF FATHER:  Breckenridge County, KY
12. MAIDEN NAME OF MOTHER:  Allice Pool
13. BIRTHPLACE OF MOTHER:  Breckenridge County, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Lume McCoy
(Address)  Stephensport, KY
15. Filed  July 1, 1912
REGISTAR:  [blank]
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  June 30, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  April 20, to June 19, 1912
That I last saw him/her alive on (date):  June 19, 1912
And that death occurred on the date stated above at (time AM/PM):  5 PM
THE CAUSE OF DEATH was as follows:  Tuberculoses
 
(Duration)   Years:      2      Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Geo. E. Shirley
Date:  7/1. 1912
Address:  Stephensport, 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:  [blank]
DATE OF BURIAL:  [blank]
20. UNDERTAKER:  Wm. J. Schopp
ADDRESS:  Stephensport, KY
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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