1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hudson
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5316
File No. 19029
Registered No: 11
1. FULL NAME: Sarah An Stone
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Jan 25, 1849
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 63yrs6mos28ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: house wife
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Grayson Co, Ky
9. NAME OF FATHER: Bluford Hack
10. BIRTHPLACE OF FATHER: Ind
11. MAIDEN NAME OF MOTHER: Elmira Graham
12. BIRTHPLACE OF MOTHER: Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Bettie Davis
(Address) Leitchfield, Ky
14. Filed Aug 23, 1912
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Aug 22, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): 10 day Aug 1912 to 22…1912 (Aug 10-22, 1912)
That I last saw him/her alive on (date): Aug 22, 1912
And that death occurred on the date stated above at (time AM/PM): 4PM
THE CAUSE OF DEATH was as follows:
Dysentery
(Duration)
Years:
Months:
Days: 18
Signed (M.D.): Dr J.W. Meador
Date: Aug 22, 1912
Address: Custer, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Holbert Cemetery
DATE OF BURIAL: Aug 23, 1912
19. UNDERTAKER: Alf Taylor
ADDRESS: Custer, Ky

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