1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  STEPHENSPORT

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  5632

Registered No:  

2.       FULL NAME:  MCCUBBINS, GEORGE

PERSONAL AND STATICAL PARTICULARS

3.       SEX:  MALE

4.       COLOR OR RACE:  WHITE

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

6.       DATE OF BIRTH:  APR 26, 1846         

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  64 / 10 / 17

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

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

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  JOHN L. MCCUBBINS

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  NAOMI PAYNE

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  LOUIS D. FOX

(Address)  STEPHENSPORT

15.   Filed  3/14

REGISTAR:  R.A. SHELLMAN

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  MAR 14, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  MAR 3, 1911 to MAR 14, 1911

That I last saw him/her alive on (date):  MAR 14, 1911

And that death occurred on the date stated above at (time AM/PM):  12:10 AM

THE CAUSE OF DEATH was as follows:  ORGANIC DISEASE OF HEART

 

(Duration)   Years:            Months:            Days:    ‘SEVERAL YEARS’

Contributory:  HYDROCOELIA

 

(Duration)   Years:            Months:            Days:  11

Signed (M.D.):  WM D. MILNER

Date:  MAR 14, 1911

Address:  UNION STAR

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:  STEPHENSON, KY

DATE OF BURIAL:  3/15/1911

20.   UNDERTAKER:  W.J. SCHOPP

ADDRESS:  STEPENSPORT