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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. Pct:  CUSTER

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  15

Primary Registration District No:  5315

File No.  21642

Registered No: 

2.       FULL NAME:  ALLEN, SUSAN ANN

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH: JUL 31, 1863

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  50 / 10 / 21

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

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

9.       BIRTHPLACE:  BRECKINRIDGE CO, KY

10.   NAME OF FATHER:  THOMAS ALLEN

11.   BIRTHPLACE OF FATHER:  KY

12.   MAIDEN NAME OF MOTHER:  SUSAN ANN ALLEN

13.   BIRTHPLACE OF MOTHER:  KY

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

(Informant)  C.E. LYNN

(Address)  CUSTER, KY

15.   Filed  SEP 12, 1912

REGISTAR:  R.O. PENNICK

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  SEP 10, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  MAR 1911 to SEP 1912

That I last saw him/her alive on (date):  SEP 4, 1912

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

THE CAUSE OF DEATH was as follows:  TUBERCULOSIS OF LUNGS

 

(Duration)   Years:     1       Months:     7       Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  R.W. MEADOR

Date:  9/12/1912

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:  GRAY GRAVE YD

DATE OF BURIAL:  SEP 12, 1912

20.   UNDERTAKER:  C.E. LYNN

ADDRESS:  

 

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Copyright.  All rights reserved.
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