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

County:  BRECKINRIDGE

Vot. Pct:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward:  4

Registration District No.:  

Primary Registration District No:  

File No.  251

Registered No: 7

2.       FULL NAME:  SCOTT, GENEVA

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE 

4.       COLOR OR RACE:  COLORED

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

6.       DATE OF BIRTH: DEC 2, 1901

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  10 / 1 / 27

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

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  JERRY SCOTT

11.   BIRTHPLACE OF FATHER:  HARDINSBURG

12.   MAIDEN NAME OF MOTHER:  TULA WHEATLY

13.   BIRTHPLACE OF MOTHER:  HARDINSBURG

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

(Informant)  JERRY SCOTT

(Address)  HARDINSBURG

15.   Filed JAN 30, 1911 

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  JAN 29, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  DEC 1911 to JAN 1911

That I last saw him/her alive on (date):  JAN 21, 1911

And that death occurred on the date stated above at (t1 PMime AM/PM):  

THE CAUSE OF DEATH was as follows:  TUBERCULOSIS - PULMONARY

 

(Duration)   Years:            Months:      6      Days:  

Contributory:  HEREDITARY

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  EDWIN A. LEX

Date:  1/29/11

Address:  HARDINSBURG

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:  COLORED CEMETERY

DATE OF BURIAL:  JAN 28, 1911

20.   UNDERTAKER:  J.T. HOBEN

ADDRESS:  HARDINSBURG



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Copyright.  All rights reserved.
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