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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.: Rockvale

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  5320

File No.29823

Registered No:  5320

2.       FULL NAME:  Orvie Mathews

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  male

4.       COLOR OR RACE:  white

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

6.       DATE OF BIRTH:  December 8th, 1912

7.       AGE (yr. mo. da) (If less than 1 day, hours or min?):  10 minutes

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  none

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

9.       BIRTHPLACE:  Kentucky

10.   NAME OF FATHER:  C. W. Mathews

11.   BIRTHPLACE OF FATHER:  Breckinridge Co. 

12.   MAIDEN NAME OF MOTHER:  Eba Mathews

13.   BIRTHPLACE OF MOTHER:  Breckinridge Co.

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

(Informant)  (unreadable) Mathews

(Address)  Fordsville,  KY

15.   Filed  12/10 1912

REGISTAR:  J. D. McDonogh

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  December 8, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Dec.  8, 1912 to Dec. 8, 1912

That I last saw him/her alive on (date):  December 8, 1912

And that death occurred on the date stated above at (time AM/PM):  2:30 pm

THE CAUSE OF DEATH was as follows:  birth palsy 

(Duration)   Years:            Months:            Days:  

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  E. P Rogers, MD

Date:  Dec 9, 1912

Address:  Fordsville, 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:  Macedonia burial ground

DATE OF BURIAL:  Dec. 10, 1912

20.   UNDERTAKER:  Cobb & Richards

ADDRESS:  Fordsville, KY


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