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Sumner County, TN. Death Records
January, 1917

Source:  TSL&A Microfilm # 73; Vital Statistics
Death Records, Volume 54
Transcribed by Jan Barnes
©2009

Name:  Bessie Neel Simpson  
Place of Death: District 10  
Sex:  Female 
Race: White  
Marital Status: Widowed  
Date of Birth: August 26, 1889  
Age:  27 years 
Occupation:  
Birthplace:  Tennessee 
Name of Father:  James Neel  
Birthplace of Father:  Tennessee 
Maiden Name of Mother: Marshall
Birthplace of Mother:  Tennessee 
Date of Death:  January 8, 1917 
Cause of Death:  Tuberculosis of the Lungs 
Length of Residence:
Place of Burial: Simpson Graveyard  
Date of Burial: January 9, 1917
Funeral Home or Undertaker: Simpson, Hodges, & Rippy, Bethpage
Informant: James Neel, Gallatin  


Name:  Sarah Ann Wallace 
Place of Death:  District 9  
Sex:  Female  
Race:  White 
Marital Status: Married  
Date of Birth:  Nov. 28, 1847 
Age: 69 years, 1 month, 25 days  
Occupation:  Housekeeper 
Birthplace:   Sumner County, Tenn. 
Name of Father:  L. Harris 
Birthplace of Father:  Tennessee 
Maiden Name of Mother: Rippy
Birthplace of Mother:  Tennessee 
Date of Death:  Jan. 23, 1917 
Cause of Death:  Cerebral hemorrhage
Length of Residence: 40 years
Place of Burial:  Gallatin, Tenn. 
Date of Burial: Jan, 25, 1917
Funeral Home or Undertaker: Harris & North, Gallatin
Informant:  Albert J. Wallace, Gallatin


Name:  McCartney, Thomas L___?  
Place of Death: District 13  
Sex:  Male 
Race:  White 
Marital Status: Married 
Date of Birth:  May 9, 1846 
Age:  72 years, 5 months, 22 days 
Occupation:  Farmer 
Birthplace:  Wilson County, Tenn. 
Name of Father: Andrew McCartney 
Birthplace of Father:  Wilson County, Tenn. 
Maiden Name of Mother: Sarah Idell
Birthplace of Mother:  Wilson County, Tenn.  
Date of Death:  January 31, 1917 
Cause of Death: Influenza
Length of Residence: (Dr. was W. L. Vickers, Adolphus, Ky.)
Place of Burial:  Highland County 
Date of Burial: February 1, 1917
Funeral Home or Undertaker: W. G. Wilkinson, Portland
Informant:  Cora Young, Adolphus, Ky.  


Name:  Savely infant 
Place of Death:  District 5, Hendersonville 
Sex:  Male 
Race:  White 
Marital Status:  Single 
Date of Birth:  Jan. 14, 1917 
Age:  
Occupation:  
Birthplace:  Hendersonville
Name of Father: William B. Savely 
Birthplace of Father:  Tenn.
Maiden Name of Mother:  Sallie Johnson
Birthplace of Mother:  Missouri
Date of Death:  January 14, 1917 
Cause of Death: Still born, cause unknown
Length of Residence:
Place of Burial:  Hendersonville 
Date of Burial:  January 15, 1917
Funeral Home or Undertaker:  Friends, Hendersonville
Informant:  William B. Savely, Hendersonville
*Two certificates for this child.  The second one has place of burial as the Family Burying Ground.  Other information is the same. 


Name:  Nannie Smith
Place of Death:  District 11, Bethpage
Sex:  Female 
Race:  Black
Marital Status: Married  
Date of Birth:  Jan. 25, 1917  (this is the birth date given on the certificate).
Age:  45 years
Occupation:  Housekeeping
Birthplace:  Tennessee
Name of Father:  All Norkings
Birthplace of Father:  Tennessee
Maiden Name of Mother: Emma? Rogan
Birthplace of Mother: Tennessee 
Date of Death:  January 25, 1917
Cause of Death:  Organic Heart Disease; Mitral Stenosis
Length of Residence:
Place of Burial:  Durham Chapel 
Date of Burial: Jan. 26, 1917
Funeral Home or Undertaker: C. L. Crowder, Gallatin 
Informant: Nell Ellis, Bethpage


Name:  Tildie Graves
Place of Death: District 17  
Sex:  Female
Race:  White
Marital Status: Married  
Date of Birth:  Feb. 5, 1887
Age:  24 years, 11 months, 15 days
Occupation:  Wife
Birthplace:  Sumner County, Tenn.
Name of Father:  Lacy Bell
Birthplace of Father:  Macon County, Tenn.
Maiden Name of Mother: Lizabeth Gregory
Birthplace of Mother:  Tenn.
Date of Death:  Jan. 20, 1917
Cause of Death: Tubercular Meningitis
Length of Residence:
Place of Burial:  Fairfield Cemetery
Date of Burial: January 21, 1917
Funeral Home or Undertaker:  W. G. Wilkinson, Portland
Informant: Ed Graves, Westmoreland, Tenn.  


Name:  Lizzie Alline Graves 
Place of Death:  District 17
Sex:  Female
Race:  White
Marital Status: Single  
Date of Birth:  Jan. 18, 1917
Age:  11 days
Occupation:  None
Birthplace:  Nubia, Tenn.
Name of Father:  Woodson Graves
Birthplace of Father:  Tenn.
Maiden Name of Mother:  Laura Ausbrooks
Birthplace of Mother:  Tenn.
Date of Death:  Jan. 25, 1917
Cause of Death:  Found dead in bed; it had thrash
Length of Residence:
Place of Burial:  Rippy Burial Ground
Date of Burial: Jan. 29, 1917
Funeral Home or Undertaker: Ed Thompson, Westmoreland
Informant:  Woodson Graves, Westmoreland  


Name:  Lassie H. Centers 
Place of Death:  District 17
Sex:  Female
Race:  White
Marital Status: Married  
Date of Birth:  Aug. 3, 1900
Age:  16 years, 5 months, 13 days
Occupation:  Wife
Birthplace:  Sumner County, Tenn.
Name of Father:  J. W. Wickman
Birthplace of Father:  Allen County, Ky.
Maiden Name of Mother: Susan Jent
Birthplace of Mother:  Allen Co., Ky.
Date of Death:  January 16, 1917
Cause of Death: Tuberculosis
Length of Residence:
Place of Burial:  Fairfield Cemetery
Date of Burial: January 17, 1917
Funeral Home or Undertaker:  W. G. Wilkinson, Portland
Informant:  Susan Jent, Westmoreland  


Name:  Herman Hickerson
Place of Death:  District 17
Sex:  Male
Race:  White
Marital Status: 
Date of Birth:  May 6, 1915
Age:  1 year, 8 months, 10 days 
Occupation:  
Birthplace:  Allen County, Ky.
Name of Father:   Andrew Hickerson
Birthplace of Father:  Allen County, Ky.
Maiden Name of Mother:  D. S. Jent
Birthplace of Mother:  Allen County, Ky.
Date of Death:  January 15, 1917
Cause of Death:  Tuberculosis, all it's life
Length of Residence:  
Place of Burial:  Fairfield Cemetery
Date of Burial:  January 16, 1917
Funeral Home or Undertaker:  Wes Gant, Westmoreland
Informant:  Susan Jent, Westmoreland 


Name:  Beatrice Branham 
Place of Death:  District 10
Sex:  Female
Race:  Black
Marital Status: Single  
Date of Birth:  May, 1916
Age:  9 months
Occupation:  
Birthplace:  Tennessee
Name of Father:  
Birthplace of Father:  
Maiden Name of Mother:  Branham 
Birthplace of Mother:  Tennessee
Date of Death:  January 24, 1917
Cause of Death:  Bronchio Pneumonia
Length of Residence:
Place of Burial:  Kansas Burying Ground
Date of Burial:  January 25, 1917
Funeral Home or Undertaker:  Crowder, Gallatin
Informant:  Jim Branham, Gallatin 


Name:  James Martin Lovell
Place of Death:  District 14 
Sex:  Male
Race:  White
Marital Status: Widowed  
Date of Birth:  Aug. 18, 1852
Age:  54 years, 4 months, 21 days
Occupation:  Farmer
Birthplace:  Sumner Co.
Name of Father:  Joe Lovell
Birthplace of Father:  White Co., Tenn.
Maiden Name of Mother:  Emily West
Birthplace of Mother:  Sumner Co.
Date of Death:  January 9, 1917
Cause of Death:  Heart disease, no doctor
Length of Residence:
Place of Burial:  Bush's Chapel
Date of Burial: January 10, 1917
Funeral Home or Undertaker:  None
Informant:  Mrs. Chas. Slicer, So. Tunnel, Tenn.  


Name:  Leathe Bertha Simpson 
Place of Death:  District 14
Sex:  Female
Race:  White
Marital Status: Married  
Date of Birth:  June 21, 1890
Age:  27 years, 6 months, 24 days
Occupation:  Housewife
Birthplace:  Sumner Co.
Name of Father:  T. W. West
Birthplace of Father:  Sumner Co.
Maiden Name of Mother:  Elizabeth Bennett
Birthplace of Mother:  
Date of Death:  Jan. 15, 1917
Cause of Death:  Pneumonia
Length of Residence:  
Place of Burial:  Rock Bridge
Date of Burial:  Jan. 16, 1917
Funeral Home or Undertaker: Simpson & Hodges & Rippy, Bethpage 
Informant: W. B. Simpson, Bethpage  


Name:  Henry Clay Bloodworth
Place of Death:  District 5, Saundersville
Sex:  Male
Race:  White
Marital Status: Widowed  
Date of Birth:  Sept. 4, 1917  (as written on certificate)
Age:  72 years, 4 months, 25 days 
Occupation:  Farming
Birthplace:  Tennessee
Name of Father:  William Bloodworth
Birthplace of Father:  Tennessee
Maiden Name of Mother: Vincy (Viney?) Strader
Birthplace of Mother: Tennessee 
Date of Death:  Jan. 29, 1917
Cause of Death:  Aortic regurgitation
Length of Residence:
Place of Burial:  Beech Burying Ground
Date of Burial:  1/30/17
Funeral Home or Undertaker: Mr. Cole
Informant:  L. C. Bloodworth, Saundersville, Tenn.   


Name:  Alex Baker
Place of Death:  District 9, Green
Sex:  Male
Race:  Colored
Marital Status:  Widower 
Date of Birth:  no data, 1845
Age:  72 years
Occupation:  Farmer
Birthplace:  Sumner Co.
Name of Father:  don't know
Birthplace of Father:  don't know
Maiden Name of Mother:  Moine Baker
Birthplace of Mother:  don't know
Date of Death:  Jan. 23, 1917
Cause of Death: Appendicitis
Length of Residence: no data, in state 72 years
Place of Burial:  Village Green
Date of Burial:  Jan. 25, 1917
Funeral Home or Undertaker: C. L. Crowder, Gallatin
Informant:  Archie Garrett, Long Hollow Pike 


Name:   Isaiah Peyton 
Place of Death:  District 9, Long Hollow Pike 
Sex:  Female
Race:  Colored
Marital Status:   Married 
Date of Birth:  1875
Age:  42
Occupation: Housework  
Birthplace:  Tennessee
Name of Father:  Hardie Elliott
Birthplace of Father:  Tennessee
Maiden Name of Mother:  Don't know
Birthplace of Mother:  Don't know
Date of Death:  Jan. 23, 1917
Cause of Death:  Cause of death not diagnosed.
Length of Residence:  At place of death, 7 years.  In state, 42 years
Place of Burial:  Gallatin
Date of Burial:  Jan. 24, 1917
Funeral Home or Undertaker: C. L. Crowder, Gallatin
Informant:  George Peyton, Gallatin 


Name:  John Dinning
Place of Death:  Gallatin
Sex:  Male
Race:  Colored
Marital Status:   Married 
Date of Birth:  1873
Age:  44 years
Occupation:  Cook
Birthplace:  Tennessee
Name of Father:  George Dinning
Birthplace of Father:  Tennessee
Maiden Name of Mother:  Don't know
Birthplace of Mother:  Tennessee
Date of Death:  Jan. 1, 1917
Cause of Death:  Pulmonary Tuberculosis
Length of Residence:
Place of Burial:  Hartsville
Date of Burial:   Jan. 3, 1917
Funeral Home or Undertaker: C. L. Crowder, Gallatin
Informant:  Manda Dinning, Gallatin 


Name:  Dave Skimmeyhorn
Place of Death:  District 3
Sex:  Male
Race:  White
Marital Status: Married  
Date of Birth:  May 16, 1942
Age:  74 years, 7 months, 18 days
Occupation:  None
Birthplace:  Tennessee
Name of Father:  Skimmeyhorn
Birthplace of Father:  Tennessee
Maiden Name of Mother: not known
Birthplace of Mother:  not known
Date of Death:  Jan. 3, 1917
Cause of Death: Intesticure Heplereteles?
Length of Residence: 3 years, 2 months, 2 days.  In state 74 years, 7 months, 18 days.
Place of Burial:  Gallatin Cemetery
Date of Burial: Jan 3, 1917
Funeral Home or Undertaker: Harris & North
Informant:  Eve Merritt, Gallatin 


Name:  Ettie Blackmore
Place of Death:  District 3, Gallatin
Sex:  Female
Race:  White
Marital Status: Single  
Date of Birth:  Dec. 16, 1916
Age:  19 days
Occupation:  None, infant
Birthplace:  Tennessee
Name of Father:  G. L. Blackmore
Birthplace of Father:  Tennessee
Maiden Name of Mother: Harshaw
Birthplace of Mother:  Tennessee
Date of Death:  Jan. 4, 1917
Cause of Death:  Gastro enteritis
Length of Residence:  19 days
Place of Burial:  Blackmore Graveyard
Date of Burial:  Jan. 6, 1917
Funeral Home or Undertaker: Harris & North, Gallatin
Informant:  G. L. Blackmore, Gallatin 


Name:  Emma E. Withers
Place of Death:  District 10, 15 miles on Dobbins Pike
Sex:  Female
Race:  White
Marital Status: Widow  
Date of Birth:  Dec. 10, 1852
Age:  64 years, 27 days
Occupation:  Housekeeper
Birthplace:  Va.
Name of Father: McKelley  
Birthplace of Father:  Va.
Maiden Name of Mother: Thomason
Birthplace of Mother:  Va.
Date of Death:  Jan. 6, 1917
Cause of Death:  Pulmonary Tuberculosis
Length of Residence:  At place of death, 40 years.  In state, 64 years
Place of Burial:  Gallatin Cemetery
Date of Burial:  Jan. 7, 1917
Funeral Home or Undertaker: Harris & North, Gallatin
Informant:  J. M. withers, Gallatin     


Name:  David Robb 
Place of Death:  District 2
Sex:  Male
Race:  Colored
Marital Status:   Single 
Date of Birth:  Not data, 1892
Age:  25 years
Occupation:  Farm-work
Birthplace:  Tennessee
Name of Father:  Henry Robb
Birthplace of Father:  Tennessee
Maiden Name of Mother:  Edder Wills
Birthplace of Mother:  Tennessee
Date of Death:  Jan. 16, 1917
Cause of Death:  Pneumonia
Length of Residence:  25 years; in state, 25 years
Place of Burial:  Cairo
Date of Burial: Jan. 17, 1917
Funeral Home or Undertaker:  C. L. Crowder, Gallatin 
Informant:  Henry Robb, Cairo, Tenn. 


Name:  Mrs. Ann Jennie Reed 
Place of Death:  District 4, Long Hollow Pike
Sex:  Female
Race:  White
Marital Status: Widow  
Date of Birth:  July 23, 1840
Age:  76 years, 5 months, 12 days
Occupation:  Housekeeper
Birthplace:  Ireland
Name of Father:  Rilley
Birthplace of Father:  France
Maiden Name of Mother:  Emmerson
Birthplace of Mother:  New York
Date of Death:  Jan. 11, 1917
Cause of Death:  Organic Poison resulting from defective kidney.  Surgical operation of one kidney.
Length of Residence:  4 years, in state 35 years.  Former of usual  residence, New York & Tennessee
Place of Burial:  Gallatin Cemetery
Date of Burial:  Jan. 13, 1917
Funeral Home or Undertaker: Harris & North, Gallatin
Informant: Emelia Christian (Col.), Gallatin  


Name:  Mrs. Mary Ellen Wheler 
Place of Death:  District 3, Gallatin
Sex:  Female
Race:  White
Marital Status: Widow  
Date of Birth:  June 10, 1839
Age:  77 years, 7 months
Occupation:  Retire Housekeeper
Birthplace:  La.
Name of Father: S. Lee  
Birthplace of Father:  Miss.
Maiden Name of Mother:  D'Armond
Birthplace of Mother:  Miss.
Date of Death:  Jan. 10, 1917
Cause of Death:  Septicamonice following the removal of urficled Oerical glands  ??
Length of Residence: 25 years.  In state 26 years.
Place of Burial:  Gallatin, Tenn.
Date of Burial: Jan. 11, 1917
Funeral Home or Undertaker: Harris & North, Gallatin
Informant:  Geo. W. Pardue, Gallatin, Tennessee 


Name:  Edders Timberlick
Place of Death:  District 2
Sex:  Female 
Race:  Colored
Marital Status:  Married 
Date of Birth:  May 26, 1875
Age:  42 years
Occupation:  None
Birthplace:  Tennessee
Name of Father:  George Washington Vaughn
Birthplace of Father:  Tennessee
Maiden Name of Mother:  Manda Parker
Birthplace of Mother:  Tennessee
Date of Death:  Jan. 20, 1917
Cause of Death:  Pulmonary Tuberculosis
Length of Residence:  Former residence, Hartsville
Place of Burial:  Hartsville
Date of Burial:  Jan. 21, 1917
Funeral Home or Undertaker:  C. L. Crowder, Gallatin
Informant:  John Timberlick, Gallatin 


Name:  Joe Sweany 
Place of Death:  Gallatin, Tenn.
Sex:  Male
Race:  Col.
Marital Status: Married  
Date of Birth:  1852
Age:  65 years
Occupation:  Labor
Birthplace:  Tennessee
Name of Father:  Don't know
Birthplace of Father:  Tennessee
Maiden Name of Mother: Don't know
Birthplace of Mother:  Tennessee
Date of Death:  Jan. 26, 1917
Cause of Death: Tuberculosis of the Lungs
Length of Residence:  30 years.  In state, 65 years
Place of Burial:  Gallatin
Date of Burial: Jan. 27, 1917
Funeral Home or Undertaker: C. L. Crowder, Gallatin
Informant:  Jessie Sweany, Nashville 


Name:  Milton W. Chenault
Place of Death:  District 19, Castalian Springs
Sex:  Male
Race:  White
Marital Status: Married  
Date of Birth:  June 1, 1849
Age:  67 years, 7 months, 26 days
Occupation:  Farmer
Birthplace:  Tennessee
Name of Father:  D. Chenault
Birthplace of Father:  Kentucky
Maiden Name of Mother: Vuensberry (
Cushenberry, perhaps)
Birthplace of Mother:  Kentucky
Date of Death:  Jan. 27, 1917
Cause of Death:  Brights Disease
Length of Residence:  10 years, in state 67 years, 7 months, 20 days
Place of Burial:  Chenault Grave Yard
Date of Burial: Jan. 28, 1917
Funeral Home or Undertaker: Harris & North, Gallatin
Informant: D. F. Barry, Gallatin 


Name:  Virgil Lee Summers
Place of Death:  District 16
Sex:  Male
Race:  White
Marital Status: Married  
Date of Birth:  April 30, 1885
Age:  31 years, 8 months, 23 days
Occupation:  Minister of the Gospel
Birthplace:  Tennessee
Name of Father:  John Logan Summers
Birthplace of Father:  Tennessee
Maiden Name of Mother: Ella Briley
Birthplace of Mother:  Tennessee
Date of Death:  Jan. 24, 1917
Cause of Death:  Tuberculosis of Lungs
Length of Residence:  
Place of Burial:  Briley Cemetery
Date of Burial:  1-25-17
Funeral Home or Undertaker: W. G. Wilkinson, Portland
Informant:  B. F. Jernigan, Portland 


Name:  Edwin Taylor
Place of Death:  District 16
Sex:  Male
Race:  White
Marital Status: Married  
Date of Birth:  Dec. 30, 1835
Age:  81 years
Occupation:  Blacksmith
Birthplace:  Sumner Co., Tenn.
Name of Father:  David Taylor
Birthplace of Father:  Virginia
Maiden Name of Mother: Fanie Russell
Birthplace of Mother:  Virginia
Date of Death:  Jan. 2, 1917
Cause of Death: Pneumonia
Length of Residence:
Place of Burial:  Ebenezer Cemetery
Date of Burial: Jan. 4, 1917
Funeral Home or Undertaker: W. G. Wilkinson, Portland
Informant:  John Taylor, Mitchellville, Tenn. 


Name:  R. L. Broadrick
Place of Death:  District 15
Sex:  Male
Race:  White
Marital Status: Infant
Date of Birth:  6-8-1916
Age:  8 months, 22 days
Occupation:  
Birthplace:  Tenn.
Name of Father:  Clide Broadrick
Birthplace of Father:  Tennessee
Maiden Name of Mother: Ivie Broadrick
Birthplace of Mother:  Tenn.
Date of Death:  1-31-1917
Cause of Death: Polmyelitis
Length of Residence:
Place of Burial:  Cole Cemetery
Date of Burial: 1-1-1917 (probably 2-1-1917, but is typed as written on certificate)
Funeral Home or Undertaker:  H. B. Wilkinson, White House
Informant:  Mrs. Broadrick


Name:  Nora Bell Clark 
Place of Death:  District 15, White House
Sex:  Female
Race:  White
Marital Status: Single  
Date of Birth:  4-8-1913
Age:  3 years, 9 months, 12 days
Occupation:  
Birthplace:  Tenn.
Name of Father:  Aaron C. Clark
Birthplace of Father:  Ky.
Maiden Name of Mother:   Ella Welch
Birthplace of Mother:  Tenn.
Date of Death:  1-20-1917
Cause of Death:  Typhoid fever with a lung complication
Length of Residence:
Place of Burial:  Eidson Cemetery
Date of Burial:  1-21-1917
Funeral Home or Undertaker: H. B. Wilkinson, White House
Informant:  W. C. Clark, White House 


Name:  Mrs. Vergie Goad 
Place of Death:  District 12, Westmoreland 
Sex:  Female
Race:  White
Marital Status:  Married  
Date of Birth:  Aug. 4, 1891
Age:  25 years, 5 months, 20 days
Occupation:  Housekeeper
Birthplace:  Sumner Co., Tenn.
Name of Father:  John Davis
Birthplace of Father:  Sumner Co., Tenn.
Maiden Name of Mother:  Annie Rhoads
Birthplace of Mother:  Sumner Co., Tenn.
Date of Death:  1-24-1917
Cause of Death:  Measles
Length of Residence:
Place of Burial:  Pleasant Grove Cemetery
Date of Burial: June 25, 1917
Funeral Home or Undertaker:  R. E. Thornton, Westmoreland
Informant:  R. E. Thornton, Westmoreland   


Name:  Joe Hayden Eddings
Place of Death:  District 12, Westmoreland
Sex:  Male
Race:  White
Marital Status: Single  
Date of Birth:  July 10, 1913
Age:  3 years, 5 months, 23 days
Occupation:  Nothing
Birthplace:  Sumner Co., Tenn.
Name of Father:  Monroe Eddings
Birthplace of Father:  Sumner Co., Tenn.
Maiden Name of Mother:  Hattie Troutt
Birthplace of Mother:  Sumner Co., Tenn.
Date of Death:  1-3-1917
Cause of Death:  Pneumonia
Length of Residence:
Place of Burial:  Troutt Burial Ground
Date of Burial: 1-4-1917
Funeral Home or Undertaker: Caldwell & Stinson, Westmoreland
Informant:   Carey Hayton, Westmoreland  


Name:  James W. Key
Place of Death:  District 12, Westmoreland
Sex:  Male
Race:  White
Marital Status: Married  
Date of Birth:  June, 1866
Age:  50 years, 7 months
Occupation:  Farmer
Birthplace:  Sumner Co., Tenn.
Name of Father:  Geo. Key
Birthplace of Father:  Sumner Co., Tenn.
Maiden Name of Mother:  Martha Perry
Birthplace of Mother:  Sumner Co., Tenn.
Date of Death:  Jan. 12, 1917
Cause of Death:  supposed to be heart failure.  Death sudden, no physician had.
Length of Residence:
Place of Burial:  New Hope Cem.
Date of Burial:  Jan. 13, 1917
Funeral Home or Undertaker:  R. E. Thornton, Westmoreland 
Informant:   R. E. Thornton, Westmoreland  


Name:  
Place of Death:  
Sex:  
Race:  
Marital Status:  
Date of Birth:  
Age:  
Occupation:  
Birthplace:  
Name of Father:  
Birthplace of Father:  
Maiden Name of Mother:
Birthplace of Mother:  
Date of Death:  
Cause of Death:
Length of Residence:
Place of Burial:  
Date of Burial:
Funeral Home or Undertaker:
Informant:     



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