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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.:  Rockvale
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5320
Primary Registration District No:  
File No.  30165
Registered No:  
2. FULL NAME:  Moxley, Sarah A.
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widowed
6. DATE OF BIRTH:  Sept. 7, 1841
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  70 yr 10 mo 8 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housekeeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge County, KY
10. NAME OF FATHER:  Samuel Godsey
11. BIRTHPLACE OF FATHER:  North Carolina
12. MAIDEN NAME OF MOTHER:  Elizabeth Shrive
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  D. H. Godsey
(Address)  Fordsville, KY
15. Filed  Nov. 17, 1911
REGISTAR:  E. L. Robertson
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Nov. 15, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Nov. 13, 1911
That I last saw him/her alive on (date):  Nov. 15, 1911
And that death occurred on the date stated above at (time AM/PM):  11 am
THE CAUSE OF DEATH was as follows:  Gastroenteritis

(Duration)   Years:            Months:            Days:  4
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  D. H. Godsey
Date:  
Address:  Fordsville, 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:  [Unreadable]
DATE OF BURIAL:  Nov. 15, 1911
20. UNDERTAKER:  T. E. Butler
ADDRESS:  Fordsville, KY

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Copyright.  All rights reserved.
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