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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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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Custer
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  20730
Registered No: 15 
2. FULL NAME:  Whitworth, Bettie
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  Dec. 4, 1871
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  39 yr 8 mo 7 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housewife
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Garfield, KY
10. NAME OF FATHER:  William Olin
11. BIRTHPLACE OF FATHER:  Custer, KY
12. MAIDEN NAME OF MOTHER:  Susan Lyons
13. BIRTHPLACE OF MOTHER:  Custer, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. C. Allgood
(Address)  Garfield, KY
15. Filed  Aug. 12, 1911
REGISTAR:  R. O. Penick
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Aug. 11, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 26, 1911
That I last saw him/her alive on (date):  Aug. 11, 1911
And that death occurred on the date stated above at (time AM/PM):  2 PM
THE CAUSE OF DEATH was as follows:  Tuberculosis Peritonitis

(Duration)   Years:            Months:      1      Days:  16
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. A. Sondbach
Date:  Aug. 12, 1911
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:  Good Hope
DATE OF BURIAL:  Aug. 12, 1911
20. UNDERTAKER:  I. B. Richardson
ADDRESS:  Garfield, KY

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Copyright.  All rights reserved.
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