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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  5306
Inc Town:  Cloverport, Ky
City:  
No.  
St.  
Ward:  
Registration District No.:  131
Primary Registration District No:  2065
File No.  27958
Registered No:  174
2.	FULL NAME:  Cooper - Stillborn
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Fem
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6.	DATE OF BIRTH:  Nov. 6, 1914
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Cloverport, Breck. Co., Ky
10.	NAME OF FATHER:  John C. Cooper
11.	BIRTHPLACE OF FATHER:  Caseyville, Ky
12.	MAIDEN NAME OF MOTHER:  Fannie M. Powell
13.	BIRTHPLACE OF MOTHER:  Coryden, Ky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  A. A. Simons
(Address)  Cloverport, Ky
15.	Filed  Nov. 6, 1914
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Nov. 6, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Nov. 6, 1914 to Nov. 6, 1914
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:  absence of cerebellum & dorsal, vertebra spines and probably cord

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  A. A. Simons, M.D.
Date:  Nov. 6, 1914
Address:  Cloverport, 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:  Cloverport, Ky
DATE OF BURIAL:  1914
20.	UNDERTAKER:  M. Humman Sons Co.
ADDRESS:  Cloverport, Ky


ADDITIONAL COMMENTS/NOTES:




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