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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Hudson
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5316
Primary Registration District No:  File No.  20324
Registered No:  10
2. FULL NAME:  
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widow
6. DATE OF BIRTH:  4 - 14, 1837
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  77 years, 4 months, 9 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housework
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  John Harrington
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  [blank]
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Benjamin Lyon
(Address)  Constantine
15. Filed  8 -23, 1914
REGISTAR:  J. H. Comer
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  8 - 23, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  7 -17, 1914 to 8 - 23, 1914
That I last saw him/her alive on (date):  8 - 19, 1914
And that death occurred on the date stated above at (time AM/PM):  4:20 PM
THE CAUSE OF DEATH was as follows:  Chronic Dysentery
 
(Duration)   Years:     3       Months:     6       Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  S. J. Hall
Date:  [blank]
Address:  Constantine
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:  Howes Valley Cemetery
DATE OF BURIAL:  8 - 24, 1914
20. UNDERTAKER:  Taylor & Gray
ADDRESS:  Custer, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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