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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:  BRECKINRIDGE

Vot. Pct:  5307

Inc Town:  CLOVERPORT

City:  

No.  

St.  

Ward:  

Registration District No.:  131

Primary Registration District No:  5307

File No.  20126

Registered No: 32

1.       FULL NAME:  DEHAVEN, MARY ELLEN CUMMINGS

PERSONAL AND STATISTICAL PARTICULARS

2.       SEX:     FEMALE

3.       COLOR OR RACE:  WHITE

4.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  WIDOW

5.       DATE OF BIRTH: MAY 8, 1843

6.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  68 / 3 / 10

7.       OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWIFE

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

8.       BIRTHPLACE:  KENTUCKY

9.       NAME OF FATHER:  HARRY CUMMINGS

10.   BIRTHPLACE OF FATHER:  KENTUKCY

11.   MAIDEN NAME OF MOTHER:  JANE EDWARDS

12.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  FREDERICK DEHAVEN

(Address)  DANVILLE, KY

14.   Filed  AUG 19, 1911

REGISTAR:  J.C. NOLTE

MEDICAL CERTIFICATE OF DEATH

15.   DATE OF DEATH:  AUG 18, 1911

16.   I HEREBY CERTIFY, That I attended deceased from (date):  “FOR SEVERAL YEARS”

That I last saw him/her alive on (date):  

And that death occurred on the date stated above at (time AM/PM):  AUG 18, 1911

THE CAUSE OF DEATH was as follows:  CHRONIC VASCULAR HEART DISEASE

 

(Duration)   Years:            Months:            Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  FREDERICK DEHAVEN

Date:  AUG 18, 1911

Address:  DANVILLE, KY

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:  CLOVERPORT

DATE OF BURIAL:  AUG 18, 1911

19.   UNDERTAKER:  M. HAMMAN & SONS

ADDRESS:  CLOVERPORT


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Copyright.  All rights reserved.
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