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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.	PLACE OF DEATH
County:  Breckinridge	
Vot. Pol.:  Stephensport
Inc Town:  Stephensport
City:  -     -
No.  
St.  
Ward
Registration District No.:  5308
Primary Registration District No:
File No.  17191
Registered No:  5308
2.	FULL NAME:  Mary E. Gardener
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Female
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married  Yes
6.	DATE OF BIRTH:  June 15th  1846
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  65 yrs 1 mos 3 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Housework
(b.)  General nature of industry business or establishment which employed:
9.	BIRTHPLACE:  Brandenburg, Meade Co.
10.	NAME OF FATHER:  Thos Smith
11.	BIRTHPLACE OF FATHER:
12.	MAIDEN NAME OF MOTHER:  Mary Smith
13.	BIRTHPLACE OF MOTHER:  Can’t read,  Mead Co.
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15.	Filed  July 18 191
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  July 18, 1911
17.	I HEREBY CERTIFY, That I attended deceased from (date):  June 5, 1911
That I last saw him/her alive on (date):  June 20, 1911
And that death occurred on the date stated above at (time AM/PM):  2 pm
THE CAUSE OF DEATH was as follows:  Septic infection from cancer of uterus

(Duration)  Years:  2     Months:  1     Days:
Contributory:  Cystitis  
(Duration):  Years:        Months:  3     Days:
Signed (M.D.):  Geo. E. Shively  M.D.
Date:  7/18/1911
Address:  Stephensport, KY
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:  Stephensport
DATE OF BURIAL:  July 19, 1911
20.	UNDERTAKER:  W. J. Schopp
ADDRESS:  Stephensport, KY
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Copyright.  All rights reserved.
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