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1.    PLACE OF DEATH

County:  Breckinridge

Vot. Pol.:  Custer

Inc Town:

City:  

No.  

St.  

Ward:  

Registration District No.:  5315

Primary Registration District No:  

File No.  11903

Registered No:  28

2.    FULL NAME:  Jennie Slaton

PERSONAL AND STATICAL PARTICULARS

3.    SEX:  female

4.    COLOR OR RACE:  white

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

6.    DATE OF BIRTH:  March 3, 1842

7.    AGE  (yr. mo. da) (If less than 1 day, hours or min?):  70 y, 2 m, 5 d

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

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

9.    BIRTHPLACE:  Ind.

10.   NAME OF FATHER:  Henry Davis

11.   BIRTHPLACE OF FATHER:  not known

12.   MAIDEN NAME OF MOTHER:  Sarah Smith

13.   BIRTHPLACE OF MOTHER:  not known

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

(Informant)  Geo Milbourne

(Address)  Custer

15.   Filed  May 8, 1912

REGISTAR:  R. O. Pennick

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  May 8, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Feb 28, 1912 to May 7, 1912

That I last saw him/her alive on (date):  May 6, 1912

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

THE CAUSE OF DEATH was as follows:  Chronic Endiocarditis

 

(Duration)   Years:            Months: 8           Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  R. W. Meador

Date:  may 8, 1912

Address:  Custer, 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:  Rosetta, KY

DATE OF BURIAL:  May 9, 1912

20.   UNDERTAKER:  Raymond Kasey

ADDRESS:  Custer, KY

 

 

ADDITIONAL COMMENTS/NOTES:Breckinridge County Cemeteries, Volume 1, page 411 shows Jennie Slaton, w/o John buried at Rosetta Cemetery, in Rosetta behind the old store.

 

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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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