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1.	PLACE OF DEATH
County:  BRECKINRIDTGE
Vot. Pol.:  CUSTER
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5315
Primary Registration District No:  15
File No.  31420
Registered No:  62
2.	FULL NAME:  AMMONS, LOLA
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  
6.	DATE OF BIRTH:  DEC 16, 1913
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  STILLBORN
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE
10.	NAME OF FATHER:  OWEN AMMONS
11.	BIRTHPLACE OF FATHER:  BRECKINRIDGE
12.	MAIDEN NAME OF MOTHER:  JENNIE F. AMMONS
13.	BIRTHPLACE OF MOTHER:  BRECKINRIDGE
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J.W. MEADOR
(Address)  CUSTER
15.	Filed  DEC 17, 1913
REGISTAR:  J.S. MITCHAM
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  DEC 16, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  STILLBORN FROM CONGENITAL HYDROCEPHALUS

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J.W. MEADOR
Date:  17 DEC 1913
Address:  CUSTER
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:  WHITWORTH CEM
DATE OF BURIAL:  DEC 17, 1913
20.	UNDERTAKER:  ALF TAYLOR
ADDRESS:  CUSTER


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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