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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.: 5307

Inc Town:

City: Cloverport KY

No.

St.

Ward 3rd

Registration District No.:

Primary Registration District No:

File No. 6179

Registered No: 53

2.       FULL NAME: Mary Ann Freeman

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: Aug 13, 1817

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 94 yrs 6 mos 21 da

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

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

9.       BIRTHPLACE: Susex England

10.   NAME OF FATHER: James Challis

11.   BIRTHPLACE OF FATHER: England

12.   MAIDEN NAME OF MOTHER: Don't Know

13.   BIRTHPLACE OF MOTHER: England

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

(Informant) Mathew W Freeman

(Address) Cloverport KY

15.   Filed Mar 5, 1912

REGISTAR: J C Nolte

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: March 4th, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date): Dec 10, 1911 to Mch 4, 1912

That I last saw him/her alive on (date): March 4th 1912

And that death occurred on the date stated above at (time AM/PM): 8:30 PM

THE CAUSE OF DEATH was as follows: Cancerous Disease

 

(Duration)

Years: 4

Months:

Days:

Signed (M.D.): Jas T Owen

Date: Mar 5, 1912

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 Cloverport KY

DATE OF BURIAL: Mar 5, 1912

20.   UNDERTAKER: M Hamman & Son

ADDRESS: Cloverport KY


 

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Copyright.  All rights reserved.
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