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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.:  5307
Inc Town:  Cloverport, KY
City:  2065
No.  131
St.  
Ward:  3
Registration District No.:  
Primary Registration District No:  
File No.  14262
Registered No:  17
2. FULL NAME:  Collins, Mattie
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widowed
6. DATE OF BIRTH:  Oct 5 1848
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  62 yr 8 mo 6 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housekeeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Tennessee	
10. NAME OF FATHER:  James L. Smith
11. BIRTHPLACE OF FATHER:  Tennessee
12. MAIDEN NAME OF MOTHER:  Betsy Klock
13. BIRTHPLACE OF MOTHER:  Tennessee
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. W. Smith
(Address)  Cloverport, KY
15. Filed  June 12, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  June 11, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 2, 1911
That I last saw him/her alive on (date):  June 11, 1911
And that death occurred on the date stated above at (time AM/PM):  11 am
THE CAUSE OF DEATH was as follows:  Diabetes Mellitus

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

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  F. L. Lightfoot
Date:  June 12, 1911
Address:  Cloverport, 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:  Cloverport, KY
DATE OF BURIAL:  June 12, 1911
20. UNDERTAKER:  M. Hamman & Son
ADDRESS:  Cloverport, KY

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Copyright.  All rights reserved.
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