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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.: Webster

Inc Town:

City:

No.

St.

Ward

Registration District No.:

Primary Registration District No:

File No. 11899

Registered No:

2.       FULL NAME: Mary Jane Gibson

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: July 30, 1845

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 66 yrs 9 mos 7 da

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

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

9.       BIRTHPLACE: Lodiburg Breckinridge Co KY

10.   NAME OF FATHER: Grayson Claycomb

11.   BIRTHPLACE OF FATHER: Kentucky

12.   MAIDEN NAME OF MOTHER: Elizabeth Gibson

13.   BIRTHPLACE OF MOTHER: Kentucky

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

(Informant) W H Gibson

(Address) 

15.   Filed: 5/7, 1912

REGISTAR: H Drane

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: May 7th, 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):

THE CAUSE OF DEATH was as follows: This subject was dead when I arrived-presumably Heart trouble to which she had been sickly.

 

(Duration) 

Years: 3 to 4

Months:

Days:

Signed (M.D.): H B Kurtz

Date:

Address:

18.   LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)

At place of death (yr, mo, da.): Visiting in Lodiburg, Breckinridge Co

In the State (yr, mo, da): 1 da

Where was disease contracted,  if not at place of death?

Former or usual residence: Cloverport KY

19.   PLACE OF BURIAL OR REMOVAL

DATE OF BURIAL:

20.   UNDERTAKER:

ADDRESS:


 

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Copyright.  All rights reserved.
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