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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.: Irvington KY

Inc Town: Irvington KY

City: 

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 239235

Registered No: 5312

2.       FULL NAME:Cora Perks Robertson

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: Black

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

6.       DATE OF BIRTH: Apr 30, 1890

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 22 yrs

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

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

9.       BIRTHPLACE: Irvington KY

10.   NAME OF FATHER: Luley Perks

11.   BIRTHPLACE OF FATHER: Webster KY

12.   MAIDEN NAME OF MOTHER: Lucy Young

13.   BIRTHPLACE OF MOTHER: Irvington KY

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

(Informant) Charles Robertson

(Address) Irvington KY

15.   Filed Apr 30, 1912

REGISTAR: D W Henry

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: April 29, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Jan 20, 1912 to Apr 29, 1912

That I last saw him/her alive on (date): April 29, 1912

And that death occurred on the date stated above at (time AM/PM): 11 PM

THE CAUSE OF DEATH was as follows: Gall Stones

 

(Duration)

Years:

Months: 4

Days: 

Contributory: Tuberculosis paritis

(Duration)

Years: 

Months: 2

Days:

Signed (M.D.): S P Parks

Date: Apr 30, 1912

Address: Irvington 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 Irvington

DATE OF BURIAL: Apr 30, 1912

20.   UNDERTAKER: G T Marshall & Son

ADDRESS: Irvington



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Copyright.  All rights reserved.
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