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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  UNION STAR
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5309
File No.  6369
Registered No:  3  
2.	FULL NAME:  PAYNE, LAURA FRENCH
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  APR 4, 1878
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  34 / 11 / 19
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWIFE
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE
10.	NAME OF FATHER:  G.R. FRENCH
11.	BIRTHPLACE OF FATHER:  BRECKINRIDGE
12.	MAIDEN NAME OF MOTHER:  ELLEN COMPTON
13.	BIRTHPLACE OF MOTHER:  BRECKINRIDGE
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J.T. SHELLMAN
(Address)  MYSTIC
15.	Filed  MAR 23, 1913
REGISTAR:  LEE STEWART
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  MAR 23, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  JAN 27, 1913 to MAR 22, 1913
That I last saw him/her alive on (date):  MAR 22, 1913
And that death occurred on the date stated above at (time AM/PM):  4 AM
THE CAUSE OF DEATH was as follows:  GASTRITIS
(Duration)   Years:            Months:       1     Days:    26
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  WILLIAM L. MILNER
Date:  MAR 23, 1913
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:  WALNUT GROVE
DATE OF BURIAL:  MAR 24, 1913
20.	UNDERTAKER:  
ADDRESS:  


ADDITIONAL COMMENTS/NOTES:




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