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1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  WEBSTER
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5311
Primary Registration District No:  11
File No.  30822
Registered No:  
2. FULL NAME:  CLAYCOMB, BERTHA
PERSONAL AND STATICAL PARTICULARS
3. SEX:  FEMALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  DEC. 23, 1914
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  STILLBORN
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  BRECKINRIDGE CO., KY
10. NAME OF FATHER:  ALLEN CLAYCOMB
11. BIRTHPLACE OF FATHER:  BRECKINRIDGE CO., KY
12. MAIDEN NAME OF MOTHER:  MARY ELLEN SUTTON
13. BIRTHPLACE OF MOTHER:  BRECKINRIDGE CO., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  
(Address)  
15. Filed  DEC 23, 1914
REGISTRAR:  G. T. MARSHALL
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  DEC. 23, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  DEC. 23, 1914
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  6 PM
THE CAUSE OF DEATH was as follows:  STILLBORN

(Duration)   Years:            Months:           Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  T. J. HENDRICK
Date:  DEC. 23, 1914
Address:  WEBSTER, KY
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:  RAYMOND (?)
DATE OF BURIAL:  DEC. 24, 1914
20. UNDERTAKER:  G. T. MARSHALL
ADDRESS:  IRVINGTON, KY