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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.:

Inc Town: Irvington

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 229234

Registered No: 5312

2.       FULL NAME: Mary Young

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: Black

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

6.       DATE OF BIRTH: 7-29, 1911

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

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

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

9.       BIRTHPLACE: Breckinridge Co

10.   NAME OF FATHER: James Young

11.   BIRTHPLACE OF FATHER: Breckinridge Co

12.   MAIDEN NAME OF MOTHER: Foot

13.   BIRTHPLACE OF MOTHER: Meade Co

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

(Informant) 

(Address)

15.   Filed April 9, 1912

REGISTAR: D W Henry

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: 4-8, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): 4-8, 1912 to 4-8, 1912

That I last saw him/her alive on (date): 4-8, 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: 

Contribution: Abcess of middle ear 

(Duration)

Years:

Months:

Days: 8

Signed (M.D.): L B Moorman

Date: 4-9, 1912

Address: Irvington

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 Irvington KY

DATE OF BURIAL: 

20.   UNDERTAKER: G T Marshall & Son

ADDRESS: Irvington KY




 

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Copyright.  All rights reserved.
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