1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  
File No.  3316
Registered No:  
2. FULL NAME:  Undgrift, Eliza Ann
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widowed
6. DATE OF BIRTH:  Dec. 20, 1844
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  67 yr 2 mo 0 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housewife
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Washington Co., KY
10. NAME OF FATHER:  Ben H. Kenney
11. BIRTHPLACE OF FATHER:  Washington Co., KY
12. MAIDEN NAME OF MOTHER:  Mary Jane Wilson
13. BIRTHPLACE OF MOTHER:  Washington Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Cuba Undgrift
(Address)  Garfield, KY
15. Filed  Feb 29 1912
REGISTRAR:  Hollis Drane
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Feb 20 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Feb 19 1912
That I last saw him/her alive on (date):  Feb 20 1912
And that death occurred on the date stated above at (time AM/PM):  2 pm
THE CAUSE OF DEATH was as follows:  Chronic bronchitis

(Duration)   Years:    7       Months:            Days:  
Contributory:  Arteriosclerosis

(Duration)   Years:   5        Months:            Days:  
Signed (M.D.):  J. A. Sandbach
Date:  Feb. 21, 1912
Address:  Garfield, 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:  
DATE OF BURIAL:  
20. UNDERTAKER:  
ADDRESS:  

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