1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  HUDSON

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  2862

Registered No:  3

2.       FULL NAME:  MCADAMS, MARTHA MATTINGLY

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  FEMALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  NOT KNOWN

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  INFORMED AT 55

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

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

9.       BIRTHPLACE:  BRECKINRIDGE 

10.   NAME OF FATHER:  BILLIE MATTINGLY

11.   BIRTHPLACE OF FATHER:  NOT KNOWN

12.   MAIDEN NAME OF MOTHER:  SPENCER

13.   BIRTHPLACE OF MOTHER:  NOT KNOWN

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

(Informant)  FAMILY

(Address)  HUDSON

15.   Filed  2/5/1911

REGISTAR:  J.H. CONNER

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  FEB 2, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  JAN 31, 1911 to FEB 2, 1911

That I last saw him/her alive on (date):  FEB 2, 1911

And that death occurred on the date stated above at (time AM/PM):  6 PM

THE CAUSE OF DEATH was as follows:  UREMIA

 

(Duration)   Years:            Months:            Days:  

Contributory:  SICK

 

(Duration)   Years:            Months:            Days:  4

Signed (M.D.):  H.C. STONE

Date:  FEB 3, 1911

Address:  CONSTANTINE, 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:  MCADAMS GRAVEYARD

DATE OF BURIAL:  2/4/1911

20.   UNDERTAKER:  CHAS. BLAIR

ADDRESS:  HUDSON