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1.       PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  HUDSON

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  

Primary Registration District No:  

File No.  25015

Registered No: 16

2.       FULL NAME:  TUCKER, SARAH N. QUIGGINS

PERSONAL AND STATISTICAL PARTICULARS

3.       SEX:     FEMALE

4.       COLOR OR RACE:  WHITE

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED

6.       DATE OF BIRTH: JAN 29, 1868

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?):  43 / 8 / 23

8.       OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWORK

(b.)  General nature of industry business or establishment which employed:  

9.       BIRTHPLACE:  KENTUCKY

10.   NAME OF FATHER:  J.R.W. QUIGGINS

11.   BIRTHPLACE OF FATHER:  KENTUCKY

12.   MAIDEN NAME OF MOTHER:  ELIZABETH  HUDSON 

13.   BIRTHPLACE OF MOTHER:  KENTUCKY

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  D.J. QUIGGINS

(Address)  HUDSON

15.   Filed  10/12/1911

REGISTAR:  J.H. CONNER

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH:  OCT 6, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date):  1 JAN 1910 to JUN 5, 1911

That I last saw him/her alive on (date):  SEP 26, 1911

And that death occurred on the date stated above at ( AM/PM):  10 A.M.

THE CAUSE OF DEATH was as follows:      PNEUMOHYDROTHORACIC

 

(Duration)   Years:    1       Months:    8       Days:  5

Contributory:  CHRONIC GASTRITIS

 

(Duration)   Years:      4     Months:    8       Days:  

Signed (M.D.):  S.J. HALL

Date:  10/6/1911

Address: CONSTANTINE

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:  

DATE OF BURIAL:  

20.   UNDERTAKER:  

ADDRESS:  

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Copyright.  All rights reserved.
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