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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Stephensport
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5308
Primary Registration District No:  
File No.  219022
Registered No:  5308
2.	FULL NAME:  Blair, Lilly Horsley
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  female
4.	COLOR OR RACE:  white
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6.	DATE OF BIRTH:  
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  26 yrs.  86 mos.  46 ds.  July is written above
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  housewife
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Breckinridge Co, KY
10.	NAME OF FATHER:  Albert Horsley
11.	BIRTHPLACE OF FATHER:  Breckinridge 
12.	MAIDEN NAME OF MOTHER:  Cordia Carman
13.	BIRTHPLACE OF MOTHER:  Breckinridge
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Henry T. Dowell
(Address)  Sample, KY
15.	Filed  Aug. 29, 1912
REGISTAR:  R. A. Shellman 
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Aug. 28, 1912
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Aug. 22, 1912 to Aug. 28, 1912
That I last saw him/her alive on (date):  Aug. 28, 1912
And that death occurred on the date stated above at (time AM/PM):  12 a.m. ??
THE CAUSE OF DEATH was as follows:  
Tuberculosis of Lungs
(Duration)   Years:      1      Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Wm. L. Milner
Date:  8/28/1912
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:  Sample, KY
DATE OF BURIAL:  Aug. 29, 1912
20.	UNDERTAKER:  W. J. Schopp
ADDRESS:  Stephensport, KY


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Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
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