1. PLACE OF DEATH
County: Breckinridge
Ward 3
Registration District No.: 136 ??
Primary Registration District No: 5303
File No. 27661
Registered No: 68
2. FULL NAME: Elder, J. Genivive
PERSONAL AND STATICAL PARTICULARS
3. SEX: female
4. COLOR OR RACE: white American
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
6. DATE OF BIRTH: Jun2 7, 1892
7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 19 yrs. 6 mos 15 ds.
8. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.) General nature of industry business or establishment which employed:
9. BIRTHPLACE: Breckinridge County, KY
10. NAME OF FATHER: Thomas N. Elder
11. BIRTHPLACE OF FATHER: Breckinridge County, KY
12. MAIDEN NAME OF MOTHER: Dessie Elder
13. BIRTHPLACE OF MOTHER: Breckinridge County, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Tom Elder
(Address) Hardinsburg, KY
15. Filed Nov. 23, 1911
REGISTAR: W. B. Lennore
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: November 22, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date): August, 1911 to November 22, 1911
That I last saw him/her alive on (date): November 10, 1911
And that death occurred on the date stated above at (time AM/PM): 5 p.m.
THE CAUSE OF DEATH was as follows:
Pulmonary Tuberculosis
(Duration)
Years:
Months: 9 mos.
Days:
Signed (M.D.): E. S. Lex
Date: Nov. 23, 1911
Address: Hardinsburg, 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 St. Romualds Cem.
DATE OF BURIAL: Nov. 23, 1911
20. UNDERTAKER: J. T. Hoben
ADDRESS: Hardinsburg, KY