1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Custer
Inc Town:  Custer
City:  
No.  
St.  
Ward:  
Registration District No.:  5315
Primary Registration District No:  
File No.  2632
Registered No:  2
2. FULL NAME:  Daisy Trent
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Oct. 29, 1881
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  29 yrs  2 mo  13 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Home life
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Custer
10. NAME OF FATHER:  Daniel Trent
11. BIRTHPLACE OF FATHER:  Custer
12. MAIDEN NAME OF MOTHER:  Amy Dewees
13. BIRTHPLACE OF MOTHER:  Big Spring
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. W. Trent (Brother)
(Address)  Custer
15. Filed  Jan. 14, 1911
REGISTAR:  R. O. Penick
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Jan. 13, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 1, 1908 to Jan. 11, 1911
That I last saw him/her alive on (date):  Jan. 13, 1911
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  Urenic Poision

(Duration)   Years:  3          Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. E. & R. W. Meador
Date:  Jan. 14, 1911
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:  Trent Burying Gr.
DATE OF BURIAL:  Jan. 14, 1911
20. UNDERTAKER:  R. O. Penick
ADDRESS:  Custer, Ky

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