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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  CLOVERPORT
Inc Town:  
City:  
No.  
St.  
Ward:  2nd
Registration District No.:  130
Primary Registration District No:  5302
File No.  12318
Registered No:  
2.	FULL NAME:  BLAKE, JENNIE ROSE
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  AUG 24, 1878
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  35 / 8 / 20
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEKEEPING
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  NATHANIEL BLAKE
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  MARGARET BEAVIN
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  ____ A. BEAVIN   [GIVEN NAME HARD TO CIPHER]
(Address)  CLOVERPORT
15.	Filed  MAY 13, 1914
REGISTAR:  W.B. LENNON
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  MAY 14, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  JAN 14, 1913 to MAY 14, 1914
That I last saw him/her alive on (date):  MAY 13, 1913
And that death occurred on the date stated above at (time AM/PM):  9 AM
THE CAUSE OF DEATH was as follows:  PULMONARY TUBERCULOSIS
(Duration)   Years:            Months:    16        Days:    
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J.E. KINCHELOE
Date:  MAY 14, 1914
Address:  HARDINSBURG
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:  ST ROMULAUD CEM, HARDINSBURG
DATE OF BURIAL:  MAY 15, 1914
20.	UNDERTAKER:  J.T. HOBEN
ADDRESS:  HARDINSBURG


ADDITIONAL COMMENTS/NOTES:




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