1. PLACE OF DEATH

County: BRECKINRIDGE

Vot. Pct: HARDINSBURG

Inc Town:

City:

No.

St.

Ward:

Registration District No.: 5302

Primary Registration District No:

File No. 20120

Registered No: 52

2. FULL NAME: WALES, LILLIE DEHAVEN

PERSONAL AND STATISTICAL PARTICULARS

3. SEX: FEMALE

4. COLOR OR RACE: BLACK

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

6. DATE OF BIRTH: APR 8, 1880

7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 31 / 4 11

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

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

9. BIRTHPLACE: KENTUCKY

10. NAME OF FATHER: SOL DEHAVEN

11. BIRTHPLACE OF FATHER: KENTUCKY

12. MAIDEN NAME OF MOTHER: REBECCA PETTIE

13. BIRTHPLACE OF MOTHER: KENTUCKY

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

(Informant) FELIX HUGHES

(Address) HARNED

15. Filed AUG 20, 1911

REGISTAR: W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16. DATE OF DEATH: AUG 19, 1911

17. I HEREBY CERTIFY, That I attended deceased from (date): MAY 29, 1911 to AUG 19, 1911

That I last saw him/her alive on (date): AUG 17, 1911

And that death occurred on the date stated above at (time AM/PM): 3 PM

THE CAUSE OF DEATH was as follows: ENDOMETRITIS



(Duration) Years: Months: 6 Days: 2

Contributory: SEPTICEMIA



(Duration) Years: Months: Days:

Signed (M.D.): JOHN E. KICHELOR

Date: AUG 19, 1911

Address: HARDINSBURG

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: WALES CEMETERY

DATE OF BURIAL: AUG 20, 1911

20. UNDERTAKER: ROBT WEATHERFORD

ADDRESS: HARNED