1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  5307
Inc Town:  
City:  Cloverport, Ky
No.  
St.  
Ward:  3
Registration District No.:  5307
Primary Registration District No:  131
File No.  22676
Registered No:  38
2. FULL NAME:  Louise C. Sims
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  November 9, 1862
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  48 yrs  10 mos  21 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  House Keeper
(b.)  General nature of industry business or establishment which employed:  General House Work
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  John C. Mattingly
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Jane Beavin
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Wave Sims
(Address)  Cloverport, Ky
15. Filed  Sept. 30, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Sept. 30, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  June 14, 1911 to Aug 18, 1911
That I last saw him/her alive on (date):  Aug. 25, 1911
And that death occurred on the date stated above at (time AM/PM):  2 p.m.
THE CAUSE OF DEATH was as follows:  Tuberculer

(Duration)   Years:            Months:  10          Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  B. T. Rafferty M.D.
Date:  Sept. 30, 1911
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:  Breckinridge Co.
DATE OF BURIAL:  Oct. 1st, 1911
20. UNDERTAKER:  M. Hamman & Son
ADDRESS:  Cloverport, Ky