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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Stephensport
Inc Town:  Stephensport, KY
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  6181
Registered No:  17
2.	FULL NAME:   Black, Hullie E.
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  male
4.	COLOR OR RACE:  white
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6.	DATE OF BIRTH:  Oct. 12, 1885
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  26 yrs.  5 mos.  16 ds. 
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Clerk
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KY
10.	NAME OF FATHER:  William B. Black
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  Bettie Avett
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Geo. E. Shively
(Address)  Stephensport, KY
15.	Filed  Mch. 29, 1912 
REGISTAR:  R. A. Shellman
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  March 28, 1912
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Mar22, 1912 to Mar 28, 1912
That I last saw him/her alive on (date):  Mar 28, 1912
And that death occurred on the date stated above at (time AM/PM):  7 P.M.
THE CAUSE OF DEATH was as follows:  
acute nephritis
(Duration)   Years:            Months:            Days:  6
Contributory:  
Bronchitis
(Duration)   Years:            Months:            Days:  10
Signed (M.D.):  Geo. E. Shively
Date:  Mar. 29, 1912
Address:  Stephensport, 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:  Lodiburg, KY
DATE OF BURIAL:  Mar 30, 1912
20.	UNDERTAKER:  M. Hamman & Sons 
ADDRESS:  Cloverport, KY

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Copyright.  All rights reserved.
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