1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  McDaniels
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5318
File No.  9242
Registered No:  
2. FULL NAME:  Jennie Whealey
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housewife
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Grayson Co., Ky
10. NAME OF FATHER:  Not Known
11. BIRTHPLACE OF FATHER:  
12. MAIDEN NAME OF MOTHER:  Erline Baker
13. BIRTHPLACE OF MOTHER:  Grayson Co., Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  
(Address)  
15. Filed  Apr. 8, 1912
REGISTAR:  M. M. Jarboe
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  April 8, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  March 29, 1912 to April 7, 1912
That I last saw him/her alive on (date):  April 7, 1912
And that death occurred on the date stated above at (time AM/PM):  12:30 p.m.
THE CAUSE OF DEATH was as follows:  Valvular disease of the heart

(Duration)   Years:   about 15         Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. B. Lampton, M.D.
Date:  April 8, 1912
Address:  McDaniels, 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: