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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.: ROCKVALE 
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5320
Primary Registration District No: 20 
File No. 31432 
Registered No: 29 
2.	FULL NAME: KATIE MATHEWS 
PERSONAL AND STATICAL PARTICULARS
3.	SEX: FEMALE 
4.	COLOR OR RACE: WHITE  
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED: MARRIED 
6.	DATE OF BIRTH: MARCH 7, 1888 
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 25YRS 9MOS 13DS 
8.	OCCUPATION (a.) Trade, profession or particular kind of work: HOUSE KEEPER 
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE: HART CO, KY 
10.	NAME OF FATHER: ROBERT HARLOW 
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  HETTIE WADE
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) J.T. BEATY 
(Address) -------- 
15.	Filed  12/25/1913
REGISTAR: JD McDONOH 
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: DEC 20, 1913 
17.	I HEREBY CERTIFY, That I attended deceased from (date): DEC 15, 1913 TO DEC 19, 1913 
That I last saw her alive on (date):  DEC 13, 1913
And that death occurred on the date stated above at (time AM/PM): 12 NOON 
THE CAUSE OF DEATH was as follows:  
LOBAR PNEUMONIA
(Duration)   Years:            Months:            Days: 10 
Contributory:  TUBERCULOSIS OF LUNGS

(Duration)   Years:            Months: 18         Days:  
Signed (M.D.):  P.E. DEMPSTER
Date: DEC 20, 1913 
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: BEATY GRAVE YARD  
DATE OF BURIAL: DEC 21, 1913 
20.	UNDERTAKER: C.E. FORD & CO 
ADDRESS: FORDSVILLE, KY 


ADDITIONAL COMMENTS/NOTES:




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