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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  WEBSTER	
Inc Town:  WEBSTER
City:  
No.  
St.  
Ward:
Registration District No.:  5311
Primary Registration District No:  11
File No.  22925
Registered No:  
2.	FULL NAME:  SIMMONS, LOWIS GALVEN
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  SEPT 24, 1848
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  65 YR 11 MO 23 DA
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  FRANKLIN CO., VA
10.	NAME OF FATHER:  ELISHA SIMMONS
11.	BIRTHPLACE OF FATHER:  FRANKLIN CO., VA
12.	MAIDEN NAME OF MOTHER:  MATILDA PAYNE
13.	BIRTHPLACE OF MOTHER:  FRANKLIN CO., VA
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  T. J. HENDRICK
(Address)  WEBSTER, KY
15.	Filed  9/17/1914
REGISTRAR:  H. L. DRANE
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  9/14/1994
17.	I HEREBY CERTIFY, That I attended deceased from (date):  MAR 1, 1914
That I last saw him/her alive on (date):  SEPT 17, 1914
And that death occurred on the date stated above at (time AM/PM):  4 PM
THE CAUSE OF DEATH was as follows:  (OBSCURED) CAUSE FROM MORPHINE

(Duration)   Years:     1       Months:           Days:  
Contributory:  MORPHINE

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  T. J. HENDRICK
Date:  SEPT. 17 1914
Address:  WEBSTER
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:  FREEDOM, KY
DATE OF BURIAL:  SEPT 17, 1914
20.	UNDERTAKER:  G. T. MARSHALL
ADDRESS:  IRVINGTON, KY



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Copyright.  All rights reserved.
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