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1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Union Star
Inc Town:
City:
No.
St.
Ward
Registration District No.: 5309
Primary Registration District No:
File No. 6183
Registered No: 4
1. FULL NAME: Ida Stiff Canary
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: August 17, 1872
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 39yrs6mos20ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: house wife
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Breckinridge Co, Ky
9. NAME OF FATHER: John D Stiff
10. BIRTHPLACE OF FATHER: Breckinridge Co, Ky
11. MAIDEN NAME OF MOTHER: Lydia Bellow
12. BIRTHPLACE OF MOTHER: Breckinridge Co, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) J.H. Canary
(Address) Union Star
14. Filed 3/7/1912
REGISTAR: Lee Stewart
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: March 7, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Dec 1st, 1911 to March <>, 1912 
That I last saw him/her alive on (date): March 6, 1912
And that death occurred on the date stated above at (time AM/PM): 6:45 AM
THE CAUSE OF DEATH was as follows:
Pulmonary Tuberculosis
(Duration)
Years:
Months: 10
Days: 4
Contributory: Dysentery
Signed (M.D.): Wm L Milner
Date: 3/7/1912
Address: Union Star
17. 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:
18. PLACE OF BURIAL OR REMOVAL:  Union Star 
19. DATE OF BURIAL: 3/8/1912
20. UNDERTAKER: W.J. Schopp
ADDRESS: Stephensport

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Copyright.  All rights reserved.
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