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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Union Star
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5309
File No.  25213
Registered No:  9
2.	FULL NAME:  Mary Francis Beauchamp
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Female
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6.	DATE OF BIRTH:  March 28th, 1913
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 yrs  6 mos  8 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Mystic Kentucky
10.	NAME OF FATHER:  Proctor Beauchamp
11.	BIRTHPLACE OF FATHER:  Kentucky
12.	MAIDEN NAME OF MOTHER:  Daisy Macy
13.	BIRTHPLACE OF MOTHER:  Kentucky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  B. F. Beauchamp
(Address)  Mystic Ky
15.	Filed  Oct 6, 1914
REGISTAR:  Lee Stewart
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  October 6th, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 14, 1914 to April 7, 1914
That I last saw him/her alive on (date):  April 7, 1914
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  Pellagra

(Duration)   Years:            Months: 9           Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Wm. L. Milner, M.D.
Date:  Oct 6, 1914
Address:  Union Star
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:  Walnut Grove, Ky
DATE OF BURIAL:  Oct. 7, 1914
20.	UNDERTAKER:  D. S. Richardson
ADDRESS:  Union Star


ADDITIONAL COMMENTS/NOTES:




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