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1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Union Star
Inc Town:
City:
No.
St.
Ward
Registration District No.: 5309
Primary Registration District No:
File No. 11898
Registered No: 9
1. FULL NAME: Infant
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: May 30, 1912
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?):
7. OCCUPATION (a.) Trade, profession or particular kind of work: stillborn
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Breckinridge Co, Ky
9. NAME OF FATHER: Charlie A Chappell
10. BIRTHPLACE OF FATHER: Bullitt Co, Ky
11. MAIDEN NAME OF MOTHER: Molly Carl
12. BIRTHPLACE OF MOTHER: Breckinridge Co
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Charlie A Chappell
(Address) Union Star
14. Filed 5/30/1912
REGISTAR: Lee Stewart
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: May 30, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): May 30, 1912 to May 30, 1912
That I last saw him/her alive on (date): never
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.): Wm L Milner
Date: May 30, 1912
Address: Union Star
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: Union Star
DATE OF BURIAL: 5/31/1912
19. UNDERTAKER: D. S. Richardson
ADDRESS: Union Star

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