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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: Breck Co

Vot. Pol.: Union Star

Inc Town: 

City:

No.

St.

Ward

Registration District No.: 5309

Primary Registration District No:

File No. 27043

Registered No: 13

2.       FULL NAME: Stella Earl Brown

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: Aug 30, 1912

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 2 mos 13 da

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

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

9.       BIRTHPLACE: Breck Co KY

10.   NAME OF FATHER: Sam E Brown

11.   BIRTHPLACE OF FATHER: Mead Co KY

12.   MAIDEN NAME OF MOTHER: Annie French

13.   BIRTHPLACE OF MOTHER: Breck Co KY

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

(Informant) Charlie French

(Address) Mystic KY

15.   Filed 11/12, 1912

REGISTAR: Lee Stewart

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Nov 12, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Nov 11, 1912 to Nov 12, 1912

That I last saw him/her alive on (date): Nov 11, 1912

And that death occurred on the date stated above at (time AM/PM): 2:40 PM

THE CAUSE OF DEATH was as follows: Obstruction of Bowell

 

(Duration) 

Years:

Months:

Days: 2

Signed (M.D.): Wm L Milner

Date: 11/12, 1912

Address: Union Star

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  Walnut Grove Burying Ground

DATE OF BURIAL: 11/13, 1912

20.   UNDERTAKER: WJ Schopp

ADDRESS: Stephensport KY

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Copyright.  All rights reserved.
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