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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Stephensport
Inc Town:  “  , Ky
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  27961
Registered No:  64
2.	FULL NAME:  Cynthia Dowell
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Female
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widowed
6.	DATE OF BIRTH:  Jan 26, 1833
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  71 yrs  10 mos  6 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Ky
10.	NAME OF FATHER:  Eli Robbins
11.	BIRTHPLACE OF FATHER:  Ky
12.	MAIDEN NAME OF MOTHER:  Betty Hanks
13.	BIRTHPLACE OF MOTHER:  Ky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Claud Morris
(Address)  Sample, Ky
15.	Filed  Nov. 9, 1914
REGISTAR:  R. A. Hullman
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Nov. 2, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Oct. 1, 1912 to Nov. 2, 1914
That I last saw him/her alive on (date):  Nov. 1, 1914
And that death occurred on the date stated above at (time AM/PM):  7 a.m.
THE CAUSE OF DEATH was as follows:  Aortic - insuffisiency

(Duration)   Years:  2          Months:            Days:  
Contributory:  Chronic Nephritis

(Duration)   Years:  8          Months:            Days:  
Signed (M.D.):  Geo. E. Shively, M.D.
Date:  Nov. 2, 1914
Address:  Stephensport
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:  Near Sample, Ky
DATE OF BURIAL:  Nov. 4, 1914
20.	UNDERTAKER:  C. A. Tinius
ADDRESS:  Stephensport, Ky


ADDITIONAL COMMENTS/NOTES:




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