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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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PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  12

Inc Town:  IRVINGTON

City:  IRVINGTON

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  30576

Registered No: 18

1.       FULL NAME:  WALL, DAUGHTER

PERSONAL AND STATISTICAL PARTICULARS

2.       SEX:     FEMALE

3.       COLOR OR RACE:  BLACK

4.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  INFANT

5.       DATE OF BIRTH: DEC 9, 1911

6.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  14 DAYS

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

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

8.       BIRTHPLACE:  IRVINGTON

9.       NAME OF FATHER:  OVERTON HALL

10.   BIRTHPLACE OF FATHER:  BEWLEYVILLE

11.   MAIDEN NAME OF MOTHER:  AILIE MILLER

12.   BIRTHPLACE OF MOTHER:  STEPHENSPORT

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

(Informant)  MARY WALL

(Address)  IRVINGTON

14.   Filed  DEC 30, 1911

REGISTAR:  D.W. HENRY

MEDICAL CERTIFICATE OF DEATH

15.   DATE OF DEATH:  DEC 23, 1911

16.   I HEREBY CERTIFY, That I attended deceased from (date):  DEC 9, 1911 to DEC 23, 1911

That I last saw him/her alive on (date):  DEC 9, 1911

And that death occurred on the date stated above at (time AM/PM):  6 AM

THE CAUSE OF DEATH was as follows:  JUANITION FR - - -  PREMATURE BIRTH

 
(Duration)   Years:            Months:            Days:  14

Contributory:  


(Duration)   Years:            Months:            Days:  

Signed (M.D.):  S.D. PARKS

Date:  DEC 23, 1911

Address:  IRVINGTON

17.   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:  

18.   PLACE OF BURIAL OR REMOVAL:  IRVINGTON

DATE OF BURIAL:  DEC 24, 191

19.   UNDERTAKER:  ROLAND BREWER

ADDRESS:      IRVINGTON

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