1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Glen Dean
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5319
Primary Registration District No:  
File No.  21646
Registered No:  
2. FULL NAME:  Ford, Lellia May
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Jan 17, 1912
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  0 yr 7 mo 20 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  George Ford
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  Rosie Duncan
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  P. E. Dempster
(Address)  Glen Dean, KY
15. Filed  Sept 7 1912
REGISTRAR:  Mrs. M. O. Robertson
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Sept 6 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Sept 6 1912
That I last saw him/her alive on (date):  Sept 6 1912
And that death occurred on the date stated above at (time AM/PM):  5 pm
THE CAUSE OF DEATH was as follows:  Cholera infantum

(Duration)   Years:            Months:            Days:  1
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P. E. Dempster
Date:  Sept 7 1912
Address:  Glen Dean, 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:  Seaton Grave Yard
DATE OF BURIAL:  Sept. 7 1912
20. UNDERTAKER:  W. R. Pierce
ADDRESS:  Glen Dean, KY

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