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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:  STEPHENSPORT

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  5308

File No.  429

Registered No: 15

2.       FULL NAME:  EARLY, REBECCA ROBBINS

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE

4.       COLOR OR RACE:  WHITE

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  

6.       DATE OF BIRTH: 

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  60 / 0 / 0

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

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

9.       BIRTHPLACE:  BRECKINRIDGE

10.   NAME OF FATHER:  ERL ROBBINS

11.   BIRTHPLACE OF FATHER:  BRECKINRIDGE

12.   MAIDEN NAME OF MOTHER:  UNKNOWN

13.   BIRTHPLACE OF MOTHER:  UNKNOWN

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

(Informant)  HARRY STILLWELL

(Address)  STEPHENSPORT

15.   Filed  JAN 12, 1912

REGISTAR:  R.A. SHELLMAN

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  JAN 10, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  

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

And that death occurred on the date stated above at (time AM/PM):  6 PM

THE CAUSE OF DEATH was as follows: CARDIAC INSUFFICIENCY  (INFORMATION DERIVED FROM H. STILLWELL)

 

(Duration)   Years:            Months:      5      Days:  

Contributory:  GENERAL DEBILITY

 

(Duration)   Years:      3      Months:            Days:  

Signed (M.D.):  GEO. E. SHIVELY

Date:  JAN 12, 1912

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:  THOMAS BIAIR

DATE OF BURIAL:  JAN 12, 1912

20.   UNDERTAKER:  JEFF CHAPP—

21.    

ADDRESS:  STEPHENSPORT

 


 

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Copyright.  All rights reserved.
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