************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ 1. PLACE OF DEATH County: Breckinridge Vot. Pol.: Hardinsburg Inc Town: City: No. St. Ward Registration District No.: Primary Registration District No: File No. 27036 Registered No: 133 2. FULL NAME: Adaline Wilson PERSONAL AND STATICAL PARTICULARS 3. SEX: Female 4. COLOR OR RACE: White 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Married 6. DATE OF BIRTH: Dec 9, 1849 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 62 yrs 11 mos 20 da 8. OCCUPATION (a.) Trade, profession or particular kind of work: House Keeper (b.) General nature of industry business or establishment which employed: House work 9. BIRTHPLACE: Mook Breckinridge Co KY 10. NAME OF FATHER: D Piles 11. BIRTHPLACE OF FATHER: Mook Breck Co KY 12. MAIDEN NAME OF MOTHER: Jane Ventress 13. BIRTHPLACE OF MOTHER: Mook Breckinridge Co KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Dave Wilson (Address) Garfield KY 15. Filed Nov 30, 1912 REGISTAR: W B Lennon MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: Nov 29, 1912 17. I HEREBY CERTIFY, That I attended deceased from (date): Oct 28, 1912 to Nov 29, 1912 That I last saw him/her alive on (date): Nov 22, 1912 And that death occurred on the date stated above at (time AM/PM): 11 AM THE CAUSE OF DEATH was as follows: Cancer of the liver (Duration) Years: Months: 6 Days: Signed (M.D.): J A Sandbach Date: Nov 29, 1912 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 Wilson Cemetary DATE OF BURIAL: Nov 30, 1912 20. UNDERTAKER: Tom Basham ADDRESS: West View ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************