************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: STEPHENSPORT Inc Town: City: STEPHENSPORT No. St. Ward: Registration District No.: Primary Registration District No: 5308 File No. 17190 Registered No: 2. FULL NAME: DOWELL, ANNIE E. SMITH PERSONAL AND STATICAL PARTICULARS 3. SEX: FEMALE 4. COLOR OR RACE: WHITE 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: 6. DATE OF BIRTH: 1859 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 52 YRS 8. OCCUPATION (a.) Trade, profession or particular kind of work: HOUSEWORK (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: JACKSON CO, MO 10. NAME OF FATHER: OLIVER SMITH 11. BIRTHPLACE OF FATHER: 12. MAIDEN NAME OF MOTHER: 13. BIRTHPLACE OF MOTHER: 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) A.C. VARBLE (Address) SAMPLE, KY 15. Filed JUL 12, 19112 REGISTAR: R.A. HULLMAN MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: JUL 12, 1911 17. I HEREBY CERTIFY, That I attended deceased from (date): JUL 3, 1911 to JUL 13, 1911 [AS RECORDED] That I last saw him/her alive on (date): JUL 12, 1911 And that death occurred on the date stated above at (time AM/PM): 2 PM THE CAUSE OF DEATH was as follows: TYPHOID (Duration) Years: Months: Days: 20 Contributory: HEMORHAGE (Duration) Years: Months: Days: Signed (M.D.): GEORGE E. SHIVELY Date: JUL 12, 1911 Address: 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: DATE OF BURIAL: JUL 13, 1911 20. UNDERTAKER: W.J. SCHOPP ADDRESS: STEPHENSPORT ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************