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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  8
Inc Town:  Stephensport
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  24215
Registered No:  
2. FULL NAME:  Beauchamp, Massie
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  June 15, 1892
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  20 yr 4 mo 1 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housewife
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., KY
10. NAME OF FATHER:  Thomas Robertson
11. BIRTHPLACE OF FATHER:  Breckinridge Co., KY
12. MAIDEN NAME OF MOTHER:  Lettisha Dowell
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Forest Beauchamp
(Address)  Stephensport, KY
15. Filed  
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: Oct. 16, 1912 
17. I HEREBY CERTIFY, That I attended deceased from (date):  Oct. 15, 1912
That I last saw him/her alive on (date):  Oct. 15, 1912
And that death occurred on the date stated above at (time AM/PM):  7 AM
THE CAUSE OF DEATH was as follows:  Pulmonary abscess

(Duration)   Years:            Months:  4          Days:  
Contributory:  Pleurisy

(Duration)   Years:            Months:   1         Days:  
Signed (M.D.):  W. H. Wedding
Date:  Oct. 16, 1912
Address:  Cannelton, IN
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:  Stephensport
DATE OF BURIAL:  Oct. 17, 1912
20. UNDERTAKER:  W. J. Schopp
ADDRESS:  Stephensport, KY

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Copyright.  All rights reserved.
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