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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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PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pct:  9

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5309

Primary Registration District No:  

File No.  8818

Registered No: 4

1.       FULL NAME:  ROSE, AMANDA SWINK

PERSONAL AND STATISTICAL PARTICULARS

2.       SEX:     FEMALE

3.       COLOR OR RACE:  WHITE

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

5.       DATE OF BIRTH: JUL 6, 1885

6.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  25 / 9 / 11

7.       OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWIFE

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

8.       BIRTHPLACE:  BRECKINRIDGE

9.       NAME OF FATHER:  LEWIS SWINK

10.   BIRTHPLACE OF FATHER:  BRECKINRIDGE

11.   MAIDEN NAME OF MOTHER:  EMMA CLAYCOMB

12.   BIRTHPLACE OF MOTHER:  BRECKINRIDGE

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

(Informant)  LEE ROSE

(Address)  MYSTIC

14.   Filed  APR 23, 1911

REGISTAR:  LEE - - - - - - 

MEDICAL CERTIFICATE OF DEATH

15.   DATE OF DEATH:  APR 22, 1911

16.   I HEREBY CERTIFY, That I attended deceased from (date):  APR 14, 191 to APR 22, 1911

That I last saw him/her alive on (date):  APR 22, 1911

And that death occurred on the date stated above at (time AM/PM):  11:40 pm

THE CAUSE OF DEATH was as follows:  MEASLES MISSCARRIAGE – THEN PNEUMONIA LOBAR

 

(Duration)   Years:            Months:            Days:  9

Contributory:  CONGESTION

 

(Duration)   Years:            Months:            Days:  2

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

Date:  APR 23, 1911

Address:  UNION STAR

17.   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:  

18.   PLACE OF BURIAL OR REMOVAL:  FLINT ISLAND CEMETERY

DATE OF BURIAL:  

19.   UNDERTAKER:  H.J. SCHOPP

ADDRESS:  STEPHENSPORT
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Copyright.  All rights reserved.
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