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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 KY

Inc Town:

City:

No.

St.

Ward

Registration District No.: 5315

Primary Registration District No: 15

File No. 298217

Registered No: 48

2.       FULL NAME:Marih Jane Wright

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: Widow

6.       DATE OF BIRTH: Mch 28, 1840

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 71 yrs 8 mos 27 da

8.       OCCUPATION (a.) Trade, profession or particular kind of work: Housewife

(b.)  General nature of industry business or establishment which employed:

9.       BIRTHPLACE: Hardin Co KY

10.   NAME OF FATHER: Berry

11.   BIRTHPLACE OF FATHER: Dont Know

12.   MAIDEN NAME OF MOTHER: Dont Know

13.   BIRTHPLACE OF MOTHER: Dont Know

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant) Len Wright

(Address) Custer KY

15.   Filed Dec 36, 1912

REGISTAR: J T Mitcham

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Dec 25, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Dec 11, 1912 to Dec 25, 1912

That I last saw him/her alive on (date): Dec 25, 1912

And that death occurred on the date stated above at (time AM/PM): 

THE CAUSE OF DEATH was as follows: Pneumonia

 

(Duration)

Years: 

Months:

Days: 10 

Signed (M.D.): J W Meador

Date: Dec 26, 1912

Address: Custer 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 Kasey Graveyard

DATE OF BURIAL: Dec 27, 1912

20.   UNDERTAKER: Alf Taylor

ADDRESS: Custer  KY



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Copyright.  All rights reserved.
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