************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************ 1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: ROCKVALE Inc Town: City: No. St. Ward: Registration District No.: Primary Registration District No: 5320 File No. 6246 Registered No: 2. FULL NAME: GIBBINS, SUSAN EMELINE HUSS PERSONAL AND STATICAL PARTICULARS 3. SEX: FEMALE 4. COLOR OR RACE: WHITE 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: MARRIED 6. DATE OF BIRTH: AUG 20, 1840 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 74 / 7 / 2 8. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: SHELBY COUNTY 10. NAME OF FATHER: ADAM HUSS 11. BIRTHPLACE OF FATHER: SHELBY COUNTY 12. MAIDEN NAME OF MOTHER: FRY 13. BIRTHPLACE OF MOTHER: SHELBY COUNTY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) SANFORD ESKRIDGE (Address) ROCKVALE 15. Filed MAR 23, 1914 REGISTAR: J. McDONOUGH MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: MAR 22, 1914 17. I HEREBY CERTIFY, That I attended deceased from (date): MAR 10, 1914 to MAR 20, 1914 That I last saw him/her alive on (date): MAR 20, 1914 And that death occurred on the date stated above at (time AM/PM): 7 AM THE CAUSE OF DEATH was as follows: LOBAR PNEUMONIA (Duration) Years: Months: Days: 5 Contributory: (Duration) Years: Months: Days: Signed (M.D.): P.E. DEMPSTER Date: MAR 22, 1914 Address: GLEN DEAN 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: MACEDONIA DATE OF BURIAL: MAR 23, 1914 20. UNDERTAKER: H. W----- & CO ADDRESS: GLEN DEAN ADDITIONAL COMMENTS/NOTES: ************************************************************************ File contributed for use in USGenWeb Archives by: Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067 http://www.usgwarchives.net ************************************************************************