1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  1
Registration District No.:  5301
Primary Registration District No:  
File No.  22670
Registered No:  54
2. FULL NAME:  Louella Sheeraw
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  March 16, 1873
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  38 yrs  5 mos  20 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  House keeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Elza Wheatley
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Isabel Biven
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Mrs. Maggie Mattingley
(Address)  Kirk, Ky
15. Filed  Sept. 6, 1911
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Sept. 5, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 1909 to Sept 5, 1911
That I last saw him/her alive on (date):  Sept. 5, 1911
And that death occurred on the date stated above at (time AM/PM):  8:30 p.m.
THE CAUSE OF DEATH was as follows:  Chronic Gastritis

(Duration)   Years:   2         Months:   8         Days:  5
Contributory:  Miscarriage

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Jno E. Kincheloe, M.D.
Date:  Sept. 5, 1911
Address:  Hardinsburg
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:  St. Romualds Cemetery
DATE OF BURIAL:  Sept. 7, 1911
20. UNDERTAKER:  Pete Sheeran Bros
ADDRESS:  Kirk, Ky

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