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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Mook
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5317
Primary Registration District No:  
File No.  11912
Registered No:  20
2. FULL NAME:  Cynthia Jane Smith
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widow
6. DATE OF BIRTH:  Apr 4, 1840
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  73 years, 19 days
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:  Kellog Norton
11. BIRTHPLACE OF FATHER:  Ky
12. MAIDEN NAME OF MOTHER:  Celia Milam
13. BIRTHPLACE OF MOTHER:  Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Mrs. Gid Smith
(Address)  Mook, Ky
15. Filed  [blank]
REGISTAR:  [blank]
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  April 23, 1913  [stamped with DELAY]
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jany 1904 to March 11, 1912
That I last saw him/her alive on (date):  March 11, 1912
And that death occurred on the date stated above at (time AM/PM):  5:30 PM
THE CAUSE OF DEATH was as follows:  Epilepsy
 
(Duration)   Years:     about 50        Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. S. Mathew
Date:  April 24, 1913
Address:  West View, 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:  [blank]
DATE OF BURIAL:  [blank]
20. UNDERTAKER:  [blank]
ADDRESS:  [blank]
 

ADDITIONAL COMMENTS/NOTES:
 
Breckinridge County Cemeteries, Volume 1, page 415 shows Cynthia J. Smith, same dates, wife of Adam, buried at Smith Family Cemetery #1, Mook, Ky. on Bill Pile's farm.


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