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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.: 130
Primary Registration District No:  5303
File No.  31408
Registered No:  
2.	FULL NAME:  BASHAM, CRAWFORD MILTON
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH: MARCH 1, 1849
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  64 YR 9 MO 2 DA
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  FARMING
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KY
10.	NAME OF FATHER:  GEORGE BASHAM
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  SUSAN CAMBELL
13.	BIRTHPLACE OF MOTHER:  
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  C. A. TINIUS
(Address)  STEPHENSPORT, KY
15.	Filed  DEC 4, 1913
REGISTAR:  W. B. LENNON
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  DEC 3 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  NOV 17, 1913
That I last saw him/her alive on (date):  DEC 2, 1913
And that death occurred on the date stated above at (time AM/PM):  6 AM
THE CAUSE OF DEATH was as follows:  CHRONIC PARYCHAGUS NEPHRITIS FOR OVER ONE YEAR

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

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. E. KINCHELOE
Date:  DEC 3, 1913
Address:  HARDINSBURG, 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:  SAMPLE, KY
DATE OF BURIAL:  DEC 5, 1913
20.	UNDERTAKER:  B. F. BEARD & CO.
ADDRESS:  HARDINSBURG, KY


ADDITIONAL COMMENTS/NOTES:




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