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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.:  Union Star
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  5633
Registered No:  
2. FULL NAME:  Wilson, Ersia
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Mar. 24, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 yr 1 mo 3 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge
10. NAME OF FATHER:  Jeff Wilson
11. BIRTHPLACE OF FATHER:  Breckinridge
12. MAIDEN NAME OF MOTHER:  Ozella [unreadable]
13. BIRTHPLACE OF MOTHER:  Breckinridge
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Philip Brown
(Address)  Lahant, KY
15. Filed  Sept. 21, 1911
REGISTAR:  Lee Stewart
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  March 24, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  March 23, 1911
That I last saw him/her alive on (date):  March 24, 1911
And that death occurred on the date stated above at (time AM/PM):  3:33 PM
THE CAUSE OF DEATH was as follows:  Bronchopneumonia

(Duration)   Years:            Months:            Days: 2 
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  D. S. Spire
Date:  March 25, 1911
Address:  Moolyville, 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:  W. J. Schopp
ADDRESS:  Stevensport, KY

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Copyright.  All rights reserved.
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