1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hardinsburg
Inc Town:
City:
No.
St.
Ward
Registration District No.: 130
Primary Registration District No: 5301
File No. 21630
Registered No: 117
1. FULL NAME: Mary Kiper
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: 9/16/1859
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 53 yrs
7. OCCUPATION (a.) Trade, profession or particular kind of work: housekeeping
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Kentucky
9. NAME OF FATHER: <    > Bozret
10. BIRTHPLACE OF FATHER: Kentucky
11. MAIDEN NAME OF MOTHER: Mary <   >
12. BIRTHPLACE OF MOTHER: Kentucky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Anderson <  > Kiper
(Address) Hardinsburg, Ky
14. Filed Sept 17, 1912
REGISTAR: WB Lennon
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: September 16, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): September 1, 1912 to Sept 16, 1912
That I last saw him/her alive on (date): Sept 1, 1912
And that death occurred on the date stated above at (time AM/PM): 8AM
THE CAUSE OF DEATH was as follows:
Heart disease, organic
(Duration)
Years: 3
Months:
Days:
Contributory: <   >
Signed (M.D.): A M Kincheloe
Date: Sept 16, 1912
Address: Hardinsburg, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Owen Cemetery
DATE OF BURIAL: Sept 17, 1912
19. UNDERTAKER: Pete Sheeran & Bros
ADDRESS: Kirk, Ky