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1.	PLACE OF DEATH
County:  Breckinridge	
Vot. Pol.:  Glen Dean
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5319
Primary Registration District No:  19
File No.  15024
Registered No:  
2.	FULL NAME:  George Berry
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Male
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6.	DATE OF BIRTH:  Dec. 25, 1836
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 77 yrs  6 mos  9 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Tennessee
10.	NAME OF FATHER:  Don’t Know
11.	BIRTHPLACE OF FATHER:  Don’t Know
12.	MAIDEN NAME OF MOTHER:  Don’t Know
13.	BIRTHPLACE OF MOTHER:  Don’t Know
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Lonnie Berry
(Address)  Glen Dean
15.	Filed  1913
REGISTAR:  Mrs. Molly Dempster
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  June 4, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  May 28, 1913 to June 4, 1913
That I last saw him/her alive on (date):  June 4, 1913
And that death occurred on the date stated above at (time AM/PM):  1 p.m.
THE CAUSE OF DEATH was as follows:  Pneumonia

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

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P. E. Dempster, M.D.
Date:  June 4, 1913
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:  Longlick Church
DATE OF BURIAL:  June 5, 1913
20.	UNDERTAKER:  L. Green & Son
ADDRESS:  Falls of Rough, Ky


ADDITIONAL COMMENTS/NOTES:




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