1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: 5306
Inc Town:
City: Cloverport, Ky
No.
St.
Ward: 2
Registration District No.: 131
Primary Registration District No: 5306
File No. 22921
Registered No: 169
2. FULL NAME: Eliza H. Allen
PERSONAL AND STATICAL PARTICULARS
3. SEX: female
4. COLOR OR RACE: white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: widowed
6. DATE OF BIRTH: Oct 5, 1828
7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 85 years, 11 months, 16 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: Joseph B. Oglesby
11. BIRTHPLACE OF FATHER: Virginia
12. MAIDEN NAME OF MOTHER: Rosie N. Coston
13. BIRTHPLACE OF MOTHER: Maryland
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) E. B. Oglesby
(Address) Cloverport, Ky
15. Filed Sept 21, 1914
REGISTAR: J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: Sept 21, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date): Sept 1 to Sept 21, 1914
That I last saw him/her alive on (date): Sept 20, 1914
And that death occurred on the date stated above at (time AM/PM): 12:30 AM
THE CAUSE OF DEATH was as follows: Cancer Vagina etc.
(Duration) Years: Months: Days: Don't Know
Contributory:
(Duration) Years: Months: Days:
Signed (M.D.): A. A. Simmons
Date: Sept 22, 1914
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: Cloverport, Ky
DATE OF BURIAL: Sept 21, 1914
20. UNDERTAKER: M. Hammon & Son
ADDRESS: Cloverport, Ky
County: Breckinridge
Vot. Pol.: 5306
Inc Town:
City: Cloverport, Ky
No.
St.
Ward: 2
Registration District No.: 131
Primary Registration District No: 5306
File No. 22921
Registered No: 169
2. FULL NAME: Eliza H. Allen
PERSONAL AND STATICAL PARTICULARS
3. SEX: female
4. COLOR OR RACE: white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: widowed
6. DATE OF BIRTH: Oct 5, 1828
7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 85 years, 11 months, 16 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: Joseph B. Oglesby
11. BIRTHPLACE OF FATHER: Virginia
12. MAIDEN NAME OF MOTHER: Rosie N. Coston
13. BIRTHPLACE OF MOTHER: Maryland
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) E. B. Oglesby
(Address) Cloverport, Ky
15. Filed Sept 21, 1914
REGISTAR: J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: Sept 21, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date): Sept 1 to Sept 21, 1914
That I last saw him/her alive on (date): Sept 20, 1914
And that death occurred on the date stated above at (time AM/PM): 12:30 AM
THE CAUSE OF DEATH was as follows: Cancer Vagina etc.
(Duration) Years: Months: Days: Don't Know
Contributory:
(Duration) Years: Months: Days:
Signed (M.D.): A. A. Simmons
Date: Sept 22, 1914
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: Cloverport, Ky
DATE OF BURIAL: Sept 21, 1914
20. UNDERTAKER: M. Hammon & Son
ADDRESS: Cloverport, Ky
1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: 5306
Inc Town:
City: Cloverport, Ky
No.
St.
Ward: 2
Registration District No.: 131
Primary Registration District No: 5306
File No. 22921
Registered No: 169
2. FULL NAME: Eliza H. Allen
PERSONAL AND STATICAL PARTICULARS
3. SEX: female
4. COLOR OR RACE: white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: widowed
6. DATE OF BIRTH: Oct 5, 1828
7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 85 years, 11 months, 16 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: Joseph B. Oglesby
11. BIRTHPLACE OF FATHER: Virginia
12. MAIDEN NAME OF MOTHER: Rosie N. Coston
13. BIRTHPLACE OF MOTHER: Maryland
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) E. B. Oglesby
(Address) Cloverport, Ky
15. Filed Sept 21, 1914
REGISTAR: J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: Sept 21, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date): Sept 1 to Sept 21, 1914
That I last saw him/her alive on (date): Sept 20, 1914
And that death occurred on the date stated above at (time AM/PM): 12:30 AM
THE CAUSE OF DEATH was as follows: Cancer Vagina etc.
(Duration) Years: Months: Days: Don't Know
Contributory:
(Duration) Years: Months: Days:
Signed (M.D.): A. A. Simmons
Date: Sept 22, 1914
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: Cloverport, Ky
DATE OF BURIAL: Sept 21, 1914
20. UNDERTAKER: M. Hammon & Son
ADDRESS: Cloverport, Ky
County: Breckinridge
Vot. Pol.: 5306
Inc Town:
City: Cloverport, Ky
No.
St.
Ward: 2
Registration District No.: 131
Primary Registration District No: 5306
File No. 22921
Registered No: 169
2. FULL NAME: Eliza H. Allen
PERSONAL AND STATICAL PARTICULARS
3. SEX: female
4. COLOR OR RACE: white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: widowed
6. DATE OF BIRTH: Oct 5, 1828
7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 85 years, 11 months, 16 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: Joseph B. Oglesby
11. BIRTHPLACE OF FATHER: Virginia
12. MAIDEN NAME OF MOTHER: Rosie N. Coston
13. BIRTHPLACE OF MOTHER: Maryland
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) E. B. Oglesby
(Address) Cloverport, Ky
15. Filed Sept 21, 1914
REGISTAR: J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: Sept 21, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date): Sept 1 to Sept 21, 1914
That I last saw him/her alive on (date): Sept 20, 1914
And that death occurred on the date stated above at (time AM/PM): 12:30 AM
THE CAUSE OF DEATH was as follows: Cancer Vagina etc.
(Duration) Years: Months: Days: Don't Know
Contributory:
(Duration) Years: Months: Days:
Signed (M.D.): A. A. Simmons
Date: Sept 22, 1914
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: Cloverport, Ky
DATE OF BURIAL: Sept 21, 1914
20. UNDERTAKER: M. Hammon & Son
ADDRESS: Cloverport, Ky
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