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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.: 5307

Inc Town: Cloverport

City:

No.

St.

Ward 3

Registration District No.:

Primary Registration District No:

File No. 428

Registered No: 49

2.       FULL NAME: Thomas J Ryan

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Male

4.       COLOR OR RACE: White

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

6.       DATE OF BIRTH: May 10, 1858

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 53 yrs 8 mos 12 da

8.       OCCUPATION (a.) Trade, profession or particular kind of work: Stationary Engineer

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

9.       BIRTHPLACE: Indiana

10.   NAME OF FATHER: Alvin Ryan

11.   BIRTHPLACE OF FATHER: Indiana

12.   MAIDEN NAME OF MOTHER: Cynthia Weatherholt

13.   BIRTHPLACE OF MOTHER: Indiana

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

(Informant) J W Weatherholt

(Address) Cloverport KY

15.   Filed Jan 23, 1912

REGISTAR: J C Nolte

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: January 22, 1012

17.   I HEREBY CERTIFY, That I attended deceased from (date): Aug 1, 1911 to Jan 22, 1912 

That I last saw him/her alive on (date): Jan 19, 1912

And that death occurred on the date stated above at (time AM/PM): 4:10 AM

THE CAUSE OF DEATH was as follows: Paralysis Second Stroke

 

(Duration)

Years:

Months: 5

Days: 22

Signed (M.D.): C R Lightfoot

Date: Jan 22, 1912

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 Tobinsport Indiana

DATE OF BURIAL: Jan 25, 1912

20.   UNDERTAKER: M Hammam Sons

ADDRESS: Cloverport KY




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Copyright.  All rights reserved.
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