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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hudson, Ky
Inc Town:  
City:  
No.  
St.  
Ward:  4
Registration District No.:  130
Primary Registration District No:  5304
File No.  12321    ['Over' written near the top of the page]
Registered No:  
2. FULL NAME:  Annie May Rusher
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  May 7, 1904
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  9 years, 11 months, 23 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  at home
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Wm Rusher
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Letitia Blair
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Wm Rusher
(Address)  Hardinsburg, Ky
15. Filed  May 1, 1914
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  May 1, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  April 30 to May 1, 1914
That I last saw him/her alive on (date):  April 30, 1914
And that death occurred on the date stated above at (time AM/PM):  12:30 AM
THE CAUSE OF DEATH was as follows:  fractured clavicle down in to lung
 
(Duration)   Years:            Months:            Days:  8
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  John E. Kincheloe
Date:  May 1, 1914
Address:  Hardinsburg, 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:  Ben Miller Farm
DATE OF BURIAL:  May 1, 1914
20. UNDERTAKER:  J. T. Hoben
ADDRESS:  Hardinsburg, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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