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1. PLACE OF DEATH
County:  Breckenridge Ky
Vot. Pol.:  
Inc Town:  Stephensport
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  24217
Registered No:  28
2. FULL NAME:  Eugna McCoy
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  April 24, 
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  8 year, 6 months, 2 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  school child
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckenridge County, KY
10. NAME OF FATHER:  John McCoy
11. BIRTHPLACE OF FATHER:  Breckenridge
12. MAIDEN NAME OF MOTHER:  Addie Vandergraft
13. BIRTHPLACE OF MOTHER:  Breckenridge Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  [blank]
(Address)  
15. Filed  Oct 27, 1912
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Oct 26, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Oct 25 to Oct 25, 1912
That I last saw him/her alive on (date):  Oct 25, 1912
And that death occurred on the date stated above at (time AM/PM):  4 AM
THE CAUSE OF DEATH was as follows:  Membranous Croup [Diptheria]
 
(Duration)   Years:            Months:            Days:  6
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Wm. L. Milner
Date:  10/26, 1912
Address:  
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:  Family Ground, Sample, KY
DATE OF BURIAL:  Oct 27, 1912
20. UNDERTAKER:  W. J. Schopp
ADDRESS:  
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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