1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  5306
Inc Town:  Cloverport
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  6178
Registered No:  52
2. FULL NAME:  Heist, Elizabeth M.
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widowed
6. DATE OF BIRTH:  Aug. 8, 1826
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  85 yr 5 mo 26 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housekeeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  Allan A. Miller
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  Susan Berry
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J. M. L. Heist
(Address)  Cloverport, KY
15. Filed  Mar 4, 1912
REGISTRAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Mar 4, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Feb 28, 1912
That I last saw him/her alive on (date):  Mar 4, 1912
And that death occurred on the date stated above at (time AM/PM):  8:30 am
THE CAUSE OF DEATH was as follows:  Lobar pneumonia

(Duration)   Years:            Months:            Days:  7
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  A. A. Simons
Date:  Mar 4, 1912
Address:  Cloverport, 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:  Cloverport, KY
DATE OF BURIAL:  Mar 6, 1912
20. UNDERTAKER:  M. Hamman & Son
ADDRESS:  Cloverport, KY