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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:  Breckenridge

Vot. Pol.:  Stephensport, Ky

Inc Town:  Stephensport

City:  

No.  

St.  

Ward:  

Registration District No.:  5308

Primary Registration District No:  

File No.  590

Registered No:  47

2.    FULL NAME:  Samuel C. Bryant

PERSONAL AND STATICAL PARTICULARS

3.    SEX:  male

4.    COLOR OR RACE:  white

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

6.    DATE OF BIRTH:  April 7, 1853

7.    AGE  (yr. mo. da) (If less than 1 day, hours or min?): 60 y, 9 m, 6 d 

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

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

9.    BIRTHPLACE:  Perry County, Ind

10.   NAME OF FATHER:  Elexander Bryant

11.   BIRTHPLACE OF FATHER:  Kentucky

12.   MAIDEN NAME OF MOTHER:  Eliza J. Connor

13.   BIRTHPLACE OF MOTHER:  Perry County, Ind.

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

(Informant)  Geo. E. Shively

(Address)  Stephensport, Ky

15.   Filed  Jan 13, 1914

REGISTAR:  R. A. Shellman

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  Jan 13, 1914

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Nov 10, 1913 to Jan 13, 1914

That I last saw him/her alive on (date):  Jan 12, 1914

And that death occurred on the date stated above at (time AM/PM):  7 AM

THE CAUSE OF DEATH was as follows:  Pulmonary - Tuberculosis

 

(Duration)   Years:            Months:  6          Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  Geo. E. Shively

Date:  Jan 13, 1914

Address:  Stephensport, 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:  Bry---- Cemetery, Perry County, Ind

DATE OF BURIAL:  Jan 14, 1914

20.   UNDERTAKER:  W. J. Schopp

ADDRESS:  Stephensport, Ky

 

 

ADDITIONAL COMMENTS/NOTES:

 



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Copyright.  All rights reserved.
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