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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.:  Bewleyville

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  5316

File No.  16553

Registered No:  5

2.       FULL NAME:  Mrs. Ola Florence Lowery

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  female

4.       COLOR OR RACE:  white

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

6.       DATE OF BIRTH:  August 13, 1884

7.       AGE (yr. mo. da) (If less than 1 day, hours or min?):  27 years, 10 months, 26 days

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

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

9.       BIRTHPLACE:  Breckinridge Co., Ky

10.   NAME OF FATHER:  William F. King

11.   BIRTHPLACE OF FATHER:  Wane Co.

12.   MAIDEN NAME OF MOTHER:  Mary Elizabeth Beatty

13.   BIRTHPLACE OF MOTHER:  Grayson

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

(Informant)  Charlie King

(Address)  Irvington, Ky RFD #1

15.   Filed  7/13, 1912

REGISTAR:  John Compton 

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  July 9, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  March 17 to July 9, 1912

That I last saw him/her alive on (date):  July 1, 1912

And that death occurred on the date stated above at (time AM/PM):  8 am

THE CAUSE OF DEATH was as follows:  Tuberculosis Stomach & Bowels

 

(Duration)   Years:      1      Months:     2       Days:  

Contributory:  Contracted from husband

 

(Duration)   Years:       1     Months:       2     Days:  

Signed (M.D.):  R. W. Meador, MD

Date:  

Address:  Custer, 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:  [blank]

DATE OF BURIAL:  [blank]

20.   UNDERTAKER:  Alf Taylor

ADDRESS:  Custer, Ky




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Copyright.  All rights reserved.
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