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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. Pol.:  5306

Inc Town:  CLOVERPORT

City:  

No.  

St.  

Ward:  2nd

Registration131 District No.:  

Primary Registration District No:  5306

File No.  20124

Registered No: 31 

2.        FULL NAME:  DENHAM, MAUD

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  FEMALE 

4.        COLOR OR RACE:  WHITE

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

6.        DATE OF BIRTH:  OCT 4, 1884

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  27 / 10 / 14

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

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

9.        BIRTHPLACE:  BRECKINRIDGE CO

10.     NAME OF FATHER:  DOCK DENHAM

11.     BIRTHPLACE OF FATHER:  EDMONSON CO, KY

12.     MAIDEN NAME OF MOTHER:  VIRGINIA BELL WINDHAM

13.     BIRTHPLACE OF MOTHER:  EDMONSON CO, KY

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

(Informant)  CHAS H. SMART

(Address)  CLOVERPORT

15.     Filed  AUG 18, 1911

REGISTAR:  J.C. NOLTE

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  AUG 18, 1911

17.     I HEREBY CERTIFY, That I attended deceased from (date):  AUG 18, 1911 to AUG 18, 1911

That I last saw him/her alive on (date):  AUG 18, 1911

And that death occurred on the date stated above at (time AM/PM):  2:30 PM

THE CAUSE OF DEATH was as follows:  ACUTE MILIARY TUBERCULOSIS

 

(Duration)   Years:     1       Months:     8       Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  E.C. MCDONALD

Date:  AUG 18, 1911

Address:  CLOVERPORT

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:  BRECKINRIDGE CO, KY

DATE OF BURIAL:  AUG 19, 1911

20.     UNDERTAKER:  M. HAMMON & SONS

ADDRESS:  CLOVERPORT


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Copyright.  All rights reserved.
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