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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.:  1
Inc Town:  
City:  Harned
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5301
File No.  2949
Registered No:  10
2. FULL NAME:  Whitworth, Jessie
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Feb. 3, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  4 hr 30 mn
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Harned
10. NAME OF FATHER:  Lonnie Duncan
11. BIRTHPLACE OF FATHER:  Harned, KY
12. MAIDEN NAME OF MOTHER:  Ella M. Whitworth
13. BIRTHPLACE OF MOTHER:  Custer, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Eli Pile
(Address)  Harned, KY
15. Filed  Feb. 4, 1911
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Feb. 3, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Feb. 3, 1911
That I last saw him/her alive on (date):  Feb. 3, 1911
And that death occurred on the date stated above at (time AM/PM):  10 AM
THE CAUSE OF DEATH was as follows:  Baby undeveloped

(Duration)   Years:            Months:            Days:  
Contributory:  Premature birth, 8 mos

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. A. Sandbach
Date:  Feb. 3, 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:  Scott Cemetery
DATE OF BURIAL:  Feb. 4, 1911
20. UNDERTAKER:  Payne & Co.
ADDRESS:  Harned

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Copyright.  All rights reserved.
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