1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hudson, Ky
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  22686
Registered No:  15
2. FULL NAME:  Emily Tucker
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married 
6. DATE OF BIRTH:  Oct. 1, 1862
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  48 yrs  11 mos  11 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  House Work
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Hudson, Ky
10. NAME OF FATHER:  William Monroe
11. BIRTHPLACE OF FATHER:  Ky.
12. MAIDEN NAME OF MOTHER:  Nancy Hudson
13. BIRTHPLACE OF MOTHER:  Hudson, Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  G. J. Quiggins
(Address)  Hudson, Ky
15. Filed  9/13, 1911
REGISTAR:  J. H. Comer
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Sept. 11, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  May, 1911 to Sept 1, 1911
That I last saw him/her alive on (date):  8/15, 1911
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  Tuberculosis Adenitis

(Duration)   Years:  1          Months:  4          Days:  
Contributory:  Grief

(Duration)   Years:            Months:            Days:  30
Signed (M.D.):  Sidney J. Hall, M.D.
Date:  9-11-1911
Address:  Constantine, 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:  Coyle’s Grave Yard
DATE OF BURIAL:  9/12, 1911
20. UNDERTAKER:  Grayson Co. Supy. Co.
ADDRESS:  Leitchfield, Ky

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