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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Big Spring
Inc Town:  Near Big Spring Ky
City:  
No.  
St.  
Ward:  
Registration District No.:  5314
Primary Registration District No:  14
File No.  6374
Registered No:  13
2. FULL NAME:  Mrs. Sallie N. Pool
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widow
6. DATE OF BIRTH:  Nov. 15, 1835
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  77 years, 4 months, 11 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  at house with daughter
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckenridge Co., Ky
10. NAME OF FATHER:  William Perrin    
11. BIRTHPLACE OF FATHER:  VA
12. MAIDEN NAME OF MOTHER:  Sallie D. Hardin
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Willis Johnson
(Address)  Big Spring, Ky
15. Filed  April 1, 1913
REGISTAR:  J. L. Morris
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  March 26, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  December 1912 to March 24, 1913
That I last saw him/her alive on (date):  March 24, 1913
And that death occurred on the date stated above at (time AM/PM):  11 PM
THE CAUSE OF DEATH was as follows:  Abcess of Spleen
 
(Duration)   Years:            Months:            Days:  
Contributory:  Chronic Malaria & infirmities of age
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. W. Meador
Date:  March 27, 1913
Address:  Custer, 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:  Perrin Cemetery
DATE OF BURIAL:  March 28, 1913
20. UNDERTAKER:  Raymond Kasey
ADDRESS:  Custer, KY
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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