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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Glen Dean, Ky
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5319
Primary Registration District No:  19
File No.  6245
Registered No:  1
2.	FULL NAME:  Clara Roberta Berry
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Female
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6.	DATE OF BIRTH:  June 24, 1912
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 yrs  8 mo  7 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Baby
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Breckinridge Co., Ky
10.	NAME OF FATHER:  Lonnie Berry
11.	BIRTHPLACE OF FATHER:  Ky
12.	MAIDEN NAME OF MOTHER:  Mary Dalton
13.	BIRTHPLACE OF MOTHER:  Ky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Lonnie Berry
(Address)  Glen Dean, Ky
15.	Filed  March 1, 1914
REGISTAR:  Mrs. Molly Dempster
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  March 1, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  8 a.m.
THE CAUSE OF DEATH was as follows:  Died before I arrived
Cholera Infantum

(Duration)   Years:            Months:            Days: 1 
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P. E. Dempster, M.D.
Date:  March 1, 1914
Address:  Glen Dean, 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:  Long Lick Cemetery
DATE OF BURIAL:  March 2, 1914
20.	UNDERTAKER:  H. Wilson & Co.
ADDRESS:  Glen Dean, Ky


ADDITIONAL COMMENTS/NOTES:




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