************************************************************************ 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. Pct: 9 Inc Town: City: No. St. Ward: Registration District No.: Primary Registration District No: File No. 8817 Registered No: 3 2. FULL NAME: ROSE, DAUGHTER PERSONAL AND STATISTICAL PARTICULARS 3. SEX: FEMALE 4. COLOR OR RACE: WHITE 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 6. DATE OF BIRTH: APR 14, 1911 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): STILLBIRTH 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: LEE ROSE 11. BIRTHPLACE OF FATHER: BRECKINRIDGE 12. MAIDEN NAME OF MOTHER: AMMANDA DWINK 13. BIRTHPLACE OF MOTHER: BRECKINRIDGE 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) LEE ROSE (Address) MYSTIC 15. Filed APR 14, 1911 REGISTAR: LEE STEWART MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: APR 14, 1911 17. I HEREBY CERTIFY, That I attended deceased from (date): APR 14, 1911 to APR 14, 1911 That I last saw him/her alive on (date): APR 14, 1911 And that death occurred on the date stated above at (time AM/PM): 3 PM THE CAUSE OF DEATH was as follows: PREMATURE (Duration) Years: Months: Days: Contributory: MEASLES J - - - - [DOCUMENT OVERPRINT] (Duration) Years: Months: Days: Signed (M.D.): WM L. MILNER Date: APR 14, 1911 Address: UNION STAR 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: WALNUT GROVE [“NEAR MOOLEYVILLE” LINED OUT] DATE OF BURIAL: APR 14, 1911 20. UNDERTAKER: P. BEAUCHAMP ADDRESS: MYSTIC ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************