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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:  5305

Inc Town:  CLOVERPORT

City:  2065

No.  

St.  

Ward:  1

Registration District No.:  131

Primary Registration District No:  2065

File No.  17187

Registered No: 24

2.       FULL NAME:  DEAN, REBECCA

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE

4.       COLOR OR RACE:  COLORED

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE

6.       DATE OF BIRTH: JUN 18, 1910

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 / - / 17

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

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  W.M. DEAN

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  LILLIE VALENTINE

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  W.M. DEAN

(Address)  CLOVERPORT

15.   Filed  JUL 5, 1911

REGISTAR:  J.C. NOLTE

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  JUL 5, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  MAY 12, 1911 to JUL 5, 1911

That I last saw him/her alive on (date):  MAY 25, 1911

And that death occurred on the date stated above at (time AM/PM):  9 AM

THE CAUSE OF DEATH was as follows:  PULMONARY EXHAUSTION DUE TO COMPRESSION OF THE LUNGS BY DEFORMED RIBS SINCE FEB 1911

 

(Duration)   Years:            Months:            Days:  

Contributory:  RASHITIS

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  A.A. SIMMONS

Date:  JUL 5, 1911

Address:  CLVOERPORT

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

DATE OF BURIAL:  JUL 6, 1911

20.   UNDERTAKER:  M. HAMMAN & SON

ADDRESS:  CLOVERPORT

 


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