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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.:  5306
Inc Town:  Cloverport, KY
City:  
No.  
St.  
Ward:  2
Registration District No.:  
Primary Registration District No:  
File No.  14340
Registered No:  65
2.	FULL NAME:  Blair, Lucy Vincense
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  female
4.	COLOR OR RACE:  white
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6.	DATE OF BIRTH:  Jan 15, 1849
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  63 yrs.  5 mos.  15 ds.  
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  House keeper
(b.)  General nature of industry business or establishment which employed:  General House work
9.	BIRTHPLACE:  Kentucky
10.	NAME OF FATHER:  Samuel Vincense
11.	BIRTHPLACE OF FATHER:  don’t know
12.	MAIDEN NAME OF MOTHER:  Rachel Davis
13.	BIRTHPLACE OF MOTHER:  don’t know
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  W. E. Blair
(Address)  Cloverport, KY
15.	Filed  July 2, 1912
REGISTAR:  J. C. Nolte. 
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  June 30, 1912
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):  
THE CAUSE OF DEATH was as follows:  
No doctor was called – no health officer here.  
(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  
Date:  
Address:  
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:  Breckinridge Co, KY  
DATE OF BURIAL:  July 1, 1912
20.	UNDERTAKER:  M. Hammon & Sons   furnished coffin only – did not have charge of burial
ADDRESS:  Cloverport, KY

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Copyright.  All rights reserved.
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