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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.:  UNION STAR

Inc Town:  UNION STAR

City:  

No.  

St.  

Ward  

Registration District No.:  

Primary Registration District No:  

File No.   22679

Registered No: 9 

2.       FULL NAME:  HOWARD, MARTHA

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  FEMALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  AUG 19, 1876

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  35 / 0 / 28

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

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

9.       BIRTHPLACE:  OHIO COUNTY, KY

10.   NAME OF FATHER:  SANDFORD HOHIMER   [SANTFORD HORHIMER]

11.   BIRTHPLACE OF FATHER:  MADISON CO, KY

12.   MAIDEN NAME OF MOTHER:  MANDY HOHIMER [MANDY HORHONER]

13.   BIRTHPLACE OF MOTHER:  WASHINGTON CO, KY

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

(Informant)  EUGENE BEAVIN

(Address)  LAHUNT, KY

15.   Filed  SEP 17, 1911

REGISTAR:  LEE STEWART BY R.A. SHELLMAN

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  SEP 15, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  JULY 11, 1911 to AUG 21, 1911

That I last saw him/her alive on (date):  AUG 21, 1911

And that death occurred on the date stated above at (time AM/PM):  7AM

THE CAUSE OF DEATH was as follows:  PULMONARY TUBERCULOSIS

 

(Duration)  

Years:   1

Months: 2  

Days:  

Signed (M.D.):  GEO. E. SHIVELY

Date:  SEP 14, 1911

Address:  STEPHENSPORT, 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  SHELLMAN BURING GROUND

DATE OF BURIAL:  SEP 16, 1911

20.   UNDERTAKER:  W.J. SCHOPP

ADDRESS:  STEPHENSPORT, KY


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Copyright.  All rights reserved.
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