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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  5306
Inc Town:  CLOVERPORT
City:  
No.  
St.  
Ward:  2nd
Registration District No.:  131
Primary Registration District No:  2065
File No.  20312
Registered No: 166 
2.	FULL NAME:  NOEL, MARY ANN JOHNSON
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  OCT 10, 1840
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  73 / 10 / 11
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSE KEEPER
(b.)  General nature of industry business or establishment which employed:  HOUSEWORK
9.	BIRTHPLACE:  BOONE COUNTY, KY
10.	NAME OF FATHER:  THOMAS JOHNSON
11.	BIRTHPLACE OF FATHER:  DON'T KNOW
12.	MAIDEN NAME OF MOTHER:  DON'T KNOW
13.	BIRTHPLACE OF MOTHER:  DON'T KNOW
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  B.W. NOELL
(Address)  CLOVERPORT
15.	Filed  AUG 22, 1914
REGISTAR:  J.C. NOLTE
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  AUG 21, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  AUG 1909 to AUG 1914
That I last saw him/her alive on (date):  AGU 25, 1914
And that death occurred on the date stated above at (time AM/PM):  8 PM
THE CAUSE OF DEATH was as follows:  SENILITY
(Duration)   Years:            Months:            Days:    
Contributory: 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J.T. OWEN
Date:  AUG 22, 1914
Address:  CLOVERPORT
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:  AUG 22, 1914
20.	UNDERTAKER:  M. HAMMAN & SONS
ADDRESS:  CLOVERPORT


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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