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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.:  Glen Dean

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  5319

File No.  29823

Registered No:  

2.       FULL NAME:  Dora May Mathews

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  female

4.       COLOR OR RACE:  white

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

6.       DATE OF BIRTH:  Jan 8, 1899

7.       AGE (yr. mo. da) (If less than 1 day, hours or min?):  13 years, 11 months

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

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

9.       BIRTHPLACE:  Kentucky

10.   NAME OF FATHER:  Henry Mathews

11.   BIRTHPLACE OF FATHER:  Ky

12.   MAIDEN NAME OF MOTHER:  Mary Condelia Brown

13.   BIRTHPLACE OF MOTHER:  Ky

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

(Informant)  Henry Mathews

(Address)  Hardinsburg RFD

15.   Filed  Dec. 8, 1912

REGISTAR:  Mrs. M. O. Robertson

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  December 8, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Dec 1, 1912 to Dec. 7, 1912

That I last saw him/her alive on (date):  Dec 7, 1912

And that death occurred on the date stated above at (time AM/PM):  9 am

THE CAUSE OF DEATH was as follows:  Lobas Pneumonia

 

(Duration)   Years:            Months:            Days:  8

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  P. E. Dempster

Date:  Dec 8, 1912

Address:  Glen Dean, 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:  St Anthony

DATE OF BURIAL:  Dec. 9, 1912

20.   UNDERTAKER:  P. Sheeran Br. & Co.

ADDRESS:  Kirk, Ky


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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