1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  5307
Inc Town:  
City:  Cloverport, Ky
No.  
St.  
Ward:  3rd 
Registration District No.:  131
Primary Registration District No:  2065
File No.  25008
Registered No:  42
2. FULL NAME:  Rosie Eliza Tindle
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Aug. 11, 1909
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  2 yrs  2 mos  5 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  child
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., Ky
10. NAME OF FATHER:  Jack Tindle
11. BIRTHPLACE OF FATHER:  Breckinridge Co., Ky
12. MAIDEN NAME OF MOTHER:  Euphamia Thompson
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Annie Benard
(Address)  Cloverport, Ky
15. Filed  Oct. 16, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  October 16, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Oct. 16, 1911 to Oct. 16, 1911
That I last saw him/her alive on (date):  Oct. 16, 1911
And that death occurred on the date stated above at (time AM/PM):  11 a.m.
THE CAUSE OF DEATH was as follows:  Diptheria

(Duration)   Years:            Months:            Days:  4
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. C. McDonald, M.D.
Date:  Oct. 16, 1911
Address:  Cloverport, 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:  Breckinridge Co., Ky
DATE OF BURIAL:  Oct. 19, 1911
20. UNDERTAKER:  M. Hamman & Son
ADDRESS:  Cloverport, Ky

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