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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. Pol.:  Hudson
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  8822
Registered No:  5
2. FULL NAME:  West, Marget Jane
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widow
6. DATE OF BIRTH:  Apr. 11, 1834
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  77 yr 0 mo 6 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housewife
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  Joel Shrewsbury
11. BIRTHPLACE OF FATHER:  Unknown
12. MAIDEN NAME OF MOTHER:  Elizabeth Wales
13. BIRTHPLACE OF MOTHER:  Unknown
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Arthur Hagan
(Address)  Constantine, KY
15. Filed  Apr. 20, 1911
REGISTAR:  J. H. Comer
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Apr. 17, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  Apr. 6, 1911
And that death occurred on the date stated above at (time AM/PM):  3:30 AM
THE CAUSE OF DEATH was as follows:  Tuberculosis of the lungs

(Duration)   Years:   Many         Months:            Days:  
Contributory:  Hereditary

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  H. C. Stone
Date:  Apr. 17, 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:  Family burial ground
DATE OF BURIAL:  Apr. 18, 1911
20. UNDERTAKER:  H. Harrington
ADDRESS:  Constantine, KY
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Copyright.  All rights reserved.
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