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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Webster, Ky
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5311
File No.  12269
Registered No:  
2. FULL NAME:  Veronas Simmons
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widower
6. DATE OF BIRTH:  4-3, 1827
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  86 years, 27 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Virginia
10. NAME OF FATHER:  Don't Know
11. BIRTHPLACE OF FATHER:  Don't Know
12. MAIDEN NAME OF MOTHER:  Don't Know
13. BIRTHPLACE OF MOTHER:  Don't Know
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Seth Hobbs
(Address)  Garfield, Ky
15. Filed  5-4, 1913
REGISTAR:  H. Drane
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  5-1, 1913
17. I HEREBY CERTIFY, That I attended deceased from (date):  January 1910 to 5-1, 1913
That I last saw him/her alive on (date):  4-5, 1913
And that death occurred on the date stated above at (time AM/PM):  6 AM
THE CAUSE OF DEATH was as follows:  Cancer of Face
 
(Duration)   Years:     3       Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. C. Harned
Date:  5-1, 1913
Address:  Garfield, 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:  Freedom, Ky
DATE OF BURIAL:  5-2, 1913
20. UNDERTAKER:  [blank]
ADDRESS:  [blank]
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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