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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.:  5306
Inc Town:  Cloverport
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  25009
Registered No: 43 
2. FULL NAME:  Newton, Susan A.
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female,
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  June 3, 1834
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  77 yr 4 mo 27 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housekeeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  H. M. Newton
11. BIRTHPLACE OF FATHER:  England
12. MAIDEN NAME OF MOTHER:  Tabitha L. West
13. BIRTHPLACE OF MOTHER:  England
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  H. H. Newton
(Address)  Cloverport, KY
15. Filed  Oct. 31, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Oct. 30, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Oct. 28, 1911
That I last saw him/her alive on (date):  Oct. 29, 1911
And that death occurred on the date stated above at (time AM/PM):  9:15 am
THE CAUSE OF DEATH was as follows:  Exhaustion following diarrhea

(Duration)   Years:            Months:            Days:  3
Contributory:  Old age

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  A. A. Simons
Date:  Oct. 31, 1911
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
DATE OF BURIAL:  Oct. 31, 1911
20. UNDERTAKER:  M. Hamman & Son
ADDRESS:  Cloverport, KY

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Copyright.  All rights reserved.
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