1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  5307
Inc Town:  CLOVERPORT
City:  
No.  
St.  
Ward:  3rd
Registration District No.:  131
Primary Registration District No:  
File No.  25006
Registered No:  
2. FULL NAME:  TUCKER, MRS. WILLIE JANE HAWKINS
PERSONAL AND STATICAL PARTICULARS
3. SEX:  FEMALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6. DATE OF BIRTH:  JUL 16, 1886
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  25 / 2 / 21
8. OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEKEEPER
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KENTUCKY
10. NAME OF FATHER:  WILLIAM 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
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 him/her alive on (date):  SEP 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 5, 1911
Address:  CLOVERPORT
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
DATE OF BURIAL:  OCT 8, 1911
20. UNDERTAKER:  M. HAMMON
ADDRESS:  CLOVERPORT

TRANSCRIBER’S NOTE: