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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  12
Inc Town:  Irvington
City:  Irvington
No.  
St.  
Ward:  
Registration District No.:  5312
Primary Registration District No:  
File No.  24219
Registered No:  
2. FULL NAME:  Cleaver, Mary
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  Black
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Feb. 19, 1883
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  29 yr 8 mo 10 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housekeeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Irvington, KY
10. NAME OF FATHER:  Elijah Cleaver
11. BIRTHPLACE OF FATHER:  Irvington, KY
12. MAIDEN NAME OF MOTHER:  Roxy Davenport
13. BIRTHPLACE OF MOTHER:  Meade Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Elijah Cleaver
(Address)  Irvington, KY
15. Filed  Oct. 30, 1912
REGISTRAR:  D. W. Henry
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Oct. 29, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Sept 2, 1912
That I last saw him/her alive on (date):  Oct. 28, 1912
And that death occurred on the date stated above at (time AM/PM):  6 PM
THE CAUSE OF DEATH was as follows:  Abscess of brain

(Duration)   Years:            Months:     2       Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  S. P. Parks
Date:  
Address:  Irvington, 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:  Irvington, KY
DATE OF BURIAL:  Oct. 30, 1912
20. UNDERTAKER:  G. T. Marshall
ADDRESS:  Irvington, KY


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Copyright.  All rights reserved.
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