************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************

File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

************************************************************************

1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  UNION STAR
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5309
Primary Registration District No:  
File No.  26158
Registered No:  10
2.	FULL NAME:  ROBERTS, ELIZEBEATH
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  WIDOWED
6.	DATE OF BIRTH:  OCT 5, 1840
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  72 YR 11 MO 28 DA
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE CO., KY
10.	NAME OF FATHER:  MASTIN ROBERTS
11.	BIRTHPLACE OF FATHER:  CASEY CO., KY
12.	MAIDEN NAME OF MOTHER:  ELIZABETH SMITH
13.	BIRTHPLACE OF MOTHER:  GARRETT CO., KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  IRENA ROBERTS
(Address)  SAMPLE, KY
15.	Filed  OCT 6, 1913
REGISTRAR:  LEE STEWART
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  OCT 3, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  JAN 24, 1913
That I last saw him/her alive on (date):  SEPT 29, 1913
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  CHRONIC INTERSTITIAL NEPHRITIS

(Duration)   Years:    2        Months:            Days:  
Contributory:  BRONCHOPNEUMONIA

(Duration)   Years:            Months:            Days:  11
Signed (M.D.):  WILLIAM MILNER
Date:  OCT 4, 1913
Address:  UNION STAR, 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:  ST. THERESA
DATE OF BURIAL:  OCT. 5, 1913
20.	UNDERTAKER:  J. W. HARDESTY
ADDRESS:  RHODELIA, KY

 
  
************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************