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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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1.  PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  530
Inc Town:  Cloverport
City:  
No.  
St.  
Ward:  3
Registration District No.:  131
Primary Registration District No:  2068
File No.  25006
Registered No:  40
2.  FULL NAME:  Mrs. Willie Jane Tucker
PERSONAL AND STATICAL PARTICULARS
3.  SEX:  Female
4.  COLOR OR RACE:  White
5.  SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6.  DATE OF BIRTH:  July 16, 1886
7.  AGE  (yr. mo. da) (If less than 1 day, hours or min?):  25 yrs, 2 mos, 21 days
8.  OCCUPATION (a.) Trade, profession or particular kind of work:  House Keeper
(b.)  General nature of industry business or establishment which employed:  General Housework
9.  BIRTHPLACE:  Kentucky
10.  NAME OF FATHER:  Wm Hawkins
11.  BIRTHPLACE OF FATHER:  Kentucky
12.  MAIDEN NAME OF MOTHER:  Eliza Murphy
13.  BIRTHPLACE OF MOTHER:  Kentucky
14.  THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Mrs Eliza Tucker
(Address)  Cloverport, Ky
15.  Filed  Oct 8, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16.  DATE OF DEATH:  Oct 7, 1911
17.  I HEREBY CERTIFY, That I attended deceased from (date):  Aug 1, 1911 to Oct 7, 1911
That I last saw her alive on (date):  Sept 25, 1911
And that death occurred on the date stated above at (time AM/PM):  7 PM
THE CAUSE OF DEATH was as follows:  Pulmonary Tuberculosis

(Duration)   Years: 2          Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. C. McDonald
Date:  Oct 8, 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:  Cloverport, Ky
DATE OF BURIAL:  Oct 8, 1911
20.  UNDERTAKER:  M. Hamman & Son
ADDRESS:  Cloverport




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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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