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1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Custer Ky
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5310
File No. 9237
Registered No: 24
1. FULL NAME: Ruby Carman
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: April 10, 1912
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?):
7. OCCUPATION (a.) Trade, profession or particular kind of work: none
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Custer
9. NAME OF FATHER: George Harned
10. BIRTHPLACE OF FATHER: Kentucky
11. MAIDEN NAME OF MOTHER: Bettie Huffines
12. BIRTHPLACE OF MOTHER: Kentucky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) George Carman
(Address) Custer, Ky
14. Filed Apr 10, 1912
REGISTAR: R.O. Penick
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: April 10, 1912
16. 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:
Still Born
(Duration)
Years:
Months:
Days:
Signed (M.D.): R.W. Meador
Date: April 10, 1912
Address: Custer, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Private
DATE OF BURIAL: Apr 10, 1912
19. UNDERTAKER: Unofficial
ADDRESS:
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