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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.:  5307

Inc Town:  Cloverport, KY

City:  

No.  

St.  

Ward:  3rd

Registration District No.:  131

Primary Registration District No:  5307

File No.  29811

Registered No:  93

2.       FULL NAME:  Annie K Mattingly

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  female

4.       COLOR OR RACE:  white

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

6.       DATE OF BIRTH:  June 18, 1910

7.       AGE (yr. mo. da) (If less than 1 day, hours or min?):  2 years, 6 months, 13 days

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

(b.)  General nature of industry business or establishment which employed:  none

9.       BIRTHPLACE:  KY

10.   NAME OF FATHER:  David Mattingly

11.   BIRTHPLACE OF FATHER:  KY

12.   MAIDEN NAME OF MOTHER:  Maggie Mattingly

13.   BIRTHPLACE OF MOTHER:  KY

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

(Informant)  David Mattingly

(Address)  Cloverport, KY

15.   Filed  Jan 1, 1913

REGISTAR:  J.C. Nolte

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  Dec 31, 1912

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Jan 1, 1912, at intervals until Nov 1st, 1912

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

And that death occurred on the date stated above at (time AM/PM):  1 PM

THE CAUSE OF DEATH was as follows:  From what I could ascertain, death was caused by acute indigestion, having either a ____ ___________ to death. Death occurred before I arrived at the home.

 (Duration)   Years:            Months:            Days:  

Contributory:  Intestinal indigestion

 

(Duration)   Years:    1      Months:            Days:  

Signed (M.D.):  C R Lightfoot

Date:  Jan 1st 1913

Address:  Cloverport, 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:  Cloverport, KY 

DATE OF BURIAL:  1-1, 1913

20.   UNDERTAKER:  M. Hammon & Son

ADDRESS:  Cloverport, KY

 
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Copyright.  All rights reserved.
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