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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County: Breckinridge 
Vot. Pol.: Hardinsburg
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5301
File No. 30569
Registered No: 70
1. FULL NAME: Elizabeth Jane Rhodes
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: Dec 19, 1911
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 4hrs45mins
7. OCCUPATION (a.) Trade, profession or particular kind of work: At home
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Kentucky
9. NAME OF FATHER: Bernard E Rhodes
10. BIRTHPLACE OF FATHER: Kentucky
11. MAIDEN NAME OF MOTHER: Lucy Jane DeJarnette
12. BIRTHPLACE OF MOTHER: Kentucky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Walter Rhodes
(Address) Kirk, Ky
14. Filed Dec 17, 1911
REGISTAR:  WB Lennon
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Dec 17, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Dec 17, 1911 to Dec 17, 1911
That I last saw him/her alive on (date): Dec 17, 1911
And that death occurred on the date stated above at (time AM/PM): 7 (no am/pm given)
THE CAUSE OF DEATH was as follows:
Premature birth
(Duration)
Years:
Months:
Days:
Signed (M.D.): Jno. E. Kicheloe
Date: Dec 17, 1911
Address: Hardinsburg, Ky
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: St. Romuald Cemetery
DATE OF BURIAL: Dec 17, 1911
19. UNDERTAKER: Pete Sheeran & Bro
ADDRESS: Kirk, Ky

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Copyright.  All rights reserved.
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