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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:  

File No.  22669

Registered No: 55 

2.       FULL NAME:  ROBARDS, DAUGHTER

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  FEMALE            

4.       COLOR OR RACE:  BLACK

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE

6.       DATE OF BIRTH:  SEP 6, 1911

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  STILLBORN

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  

(b.)  General nature of industry business or establishment which employed:  

9.       BIRTHPLACE:  BRECKINRIDGE

10.   NAME OF FATHER:  ALFORD ALLEN ROBARDS

11.   BIRTHPLACE OF FATHER:  BRECKINRIDGE

12.   MAIDEN NAME OF MOTHER:  LIZABELLE BULAH MCDANIEL

13.   BIRTHPLACE OF MOTHER:  BRECKINRIDGE

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  ALFRED ALLEN ROBARDS

(Address)  HARDINSBURG

15.   Filed  SEP 4, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  PROBABLY TWO WEEKS BEFORE BIRTH

17.   I HEREBY CERTIFY, That I attended deceased from (date):  

That I last saw him/her alive on (date):  

And that death occurred on the date stated above at (time AM/PM):  

THE CAUSE OF DEATH was as follows:  CAUSED FROM MOTHER WORKING AND LIFTING A  __illeg___, PRODUCING UTERINE HEMMORHAGE AND DEATH BY - - ILCH

 

(Duration)   Years:            Months:            Days:  

Contributory:  PREGNANCY SIXTH MONTH

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  A.W. KINCHELOR

Date:  SEP 4, 1911

Address:  HARDINSBURG

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:  AT HOME

DATE OF BURIAL:  SEP 4, 1911

20.   UNDERTAKER:  NONE

ADDRESS: 

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Copyright.  All rights reserved.
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