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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5302

Primary Registration District No:  

File No.  20120

Registered No: 52

2.       FULL NAME:  WALES, LILLIE DEHAVEN

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE

4.       COLOR OR RACE:  BLACK

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED

6.       DATE OF BIRTH: APR 8, 1880

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  31 / 4 11

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  

(b.)  General nature of industry business or establishment which employed:  HOUSEWIFE

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  SOL DEHAVEN

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  REBECCA PETTIE

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  FELIX HUGHES

(Address)  HARNED

15.   Filed  AUG 20, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  AUG 19, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  MAY 29, 1911 to AUG 19, 1911

That I last saw him/her alive on (date):  AUG 17, 1911

And that death occurred on the date stated above at (time AM/PM):  3 PM

THE CAUSE OF DEATH was as follows:  ENDOMETRITIS

 

(Duration)   Years:            Months:      6      Days:  2

Contributory:  SEPTICEMIA

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  JOHN E. KICHELOR

Date:  AUG 19, 1911

Address:  HARDINSBURG

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:  WALES CEMETERY

DATE OF BURIAL:  AUG 20, 1911

20.   UNDERTAKER:  ROBT WEATHERFORD

ADDRESS:  HARNED



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