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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5312
File No.  12
Registered No:  
2.	FULL NAME:  GORSUCH, MARY LENA SIMMONS
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  OCTOBER 1883
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  30 / 9 / 24
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  AT HOME
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE
10.	NAME OF FATHER:  C.T. SIMMONS
11.	BIRTHPLACE OF FATHER:  MEADE COUNTY
12.	MAIDEN NAME OF MOTHER:  WILLIE A. DENT
13.	BIRTHPLACE OF MOTHER:  BRECKINRIDGE
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  H.S. GORSUCH H---FORD
(Address)  OLLINGTON [sp], KENTUCKY   [PROB IRVINGTON]
15.	Filed  OCT 24, 1914 [DELAYED]
REGISTAR:  MRS. SUE JOLLY
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  OCT 24, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  SEP 1, 1914 to OCT 24, 1914
That I last saw him/her alive on (date):  OCT 23, 1914
And that death occurred on the date stated above at (time AM/PM):  4AM
THE CAUSE OF DEATH was as follows:  TYPHOID FEVER
(Duration)   Years:              Months:            Days:    24
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  S.P. PARKS
Date:  OCT 24, 1914
Address:  IRVINGTON
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:  IRVINGTON
DATE OF BURIAL:  OCT 25, 1914
20.	UNDERTAKER:  J.L. GRAY
ADDRESS:  CUSTER


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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