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1.    PLACE OF DEATH

County:  Breckenridge County

Vot. Pol.:  Rockvale

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5320

Primary Registration District No:  

File No.  39 (written in) 5750 stamped on

Registered No:  5320

2.    FULL NAME:  Myrtle Porter

PERSONAL AND STATICAL PARTICULARS

3.    SEX:  female

4.    COLOR OR RACE:  white

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

6.    DATE OF BIRTH:  September 21, 1913

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

8.    OCCUPATION (a.) Trade, profession or particular kind of work:  None

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

9.    BIRTHPLACE:  Breckenridge

10.   NAME OF FATHER:  Andy Porter

11.   BIRTHPLACE OF FATHER:  Grayson County

12.   MAIDEN NAME OF MOTHER:  Lilly Miller

13.   BIRTHPLACE OF MOTHER:  Grayson County

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

(Informant)  Andy Porter

(Address)  Rockvale, Ky

15.   Filed  5/6, 1914

REGISTAR:  J. D. McDonogh

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  September 21, 1913

17.   I HEREBY CERTIFY, That I attended deceased from (date):  Sept 21

That I last saw him/her alive on (date):  

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

THE CAUSE OF DEATH was as follows:  Still birth

 

(Duration)   Years:            Months:            Days:  

Contributory:  burns condition of mother

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  E. P. Rodgers

Date:  Sept 21, 1913

Address:  Fordsville, 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:  Loneston Cemetery

DATE OF BURIAL:  September 22, 1913

20.   UNDERTAKER:  

ADDRESS:  

 

 

ADDITIONAL COMMENTS/NOTES:

 

 

 

 

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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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