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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.: Stephensport

Inc Town:

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 27042

Registered No: 31

2.       FULL NAME: Eliza Jane Roberts

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: Oct 18, 1833

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 79 yrs 1 mos 5 da

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

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

9.       BIRTHPLACE: Breckinridge

10.   NAME OF FATHER: Maston Roberts

11.   BIRTHPLACE OF FATHER: Pulaski Co KY

12.   MAIDEN NAME OF MOTHER: Elizabeth Smith Roberts

13.   BIRTHPLACE OF MOTHER: 

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

(Informant) Dennise Roberts

(Address) Sample KY (?)

15.   Filed Nov 23, 1912

REGISTAR: R A Shellman

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: November 23, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  1910 to Nov 1912

That I last saw him/her alive on (date): Nov 9, 1912

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

THE CAUSE OF DEATH was as follows: Cancer of (the rest is unreadable)

 

(Duration)

Years: (unreadable)

Months:

Days:

Signed (M.D.): Wm L Milner

Date: Nov 23, 1912

Address:  (unreadable)

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 Sample KY

DATE OF BURIAL: Nov 25, 1912

20.   UNDERTAKER: D S Richardson

ADDRESS: Union Star 




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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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