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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Mooleyville
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5310
Primary Registration District No:  
File No.  15  580
Registered No:  5310
2. FULL NAME:  Thosa Greenwell
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  [blank]
6. DATE OF BIRTH:  Oct 25, 1829
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  83 years, 2 months 13 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  housewife
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ill.
10. NAME OF FATHER:  don't know
11. BIRTHPLACE OF FATHER:  don't know
12. MAIDEN NAME OF MOTHER:  don't know
13. BIRTHPLACE OF MOTHER:  don't know
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  W. H. Greenwell
(Address)  Cloverport, KY
15. Filed  Jan 9, 1913
REGISTAR:  J. D. Cunningham  per Mrs. S. R. O'Bryan
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Jan 8, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  July 9, 1912 to Jan 8, 1913
That I last saw him/her alive on (date):  Jan 6, 1913
And that death occurred on the date stated above at (time AM/PM):  6:30 PM
THE CAUSE OF DEATH was as follows:  Cancer of the Face
 
(Duration)   Years:   about 2 years     Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  D. S. Spire
Date:  Jan 8, 1913
Address:  Mooleyville, 
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:  St. Teresa
DATE OF BURIAL:  Jan 9, 1913
20. UNDERTAKER:  R. C. O'Bryan
ADDRESS:  Mooleyville, 
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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