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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Mook
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5317
Primary Registration District No:  
File No.  2964
Registered No:  5
2.	FULL NAME:  Mollie Judieth Gray
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Female
4.	COLOR OR RACE:  Black
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6.	DATE OF BIRTH:  Oct 23, 1909
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 yrs  3 mos  13 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Infant
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Breckinridge, Ky
10.	NAME OF FATHER:  Paul Gray
11.	BIRTHPLACE OF FATHER:  Breckinridge
12.	MAIDEN NAME OF MOTHER:  Mary Alexander
13.	BIRTHPLACE OF MOTHER:  Breckinridge
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Henry Gray
(Address)  Mook
15.	Filed  Feb 7, 1911
REGISTAR:  V. G. Goodman
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Feb. 6, 1911
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Feb 6, 1911 to Feb 6, 1911
That I last saw him/her alive on (date):  Feb. 6, 1911
And that death occurred on the date stated above at (time AM/PM):  9 p.m.
THE CAUSE OF DEATH was as follows:  Infantile Paralysis

(Duration)   Years:            Months:            Days:  2
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  R. W. Meador
Date:  Feb 7, 1911
Address:  Custer, 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:  Pil Grave Yard
DATE OF BURIAL:  Feb 8, 1911
20.	UNDERTAKER:  James Cox
ADDRESS:  
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Copyright.  All rights reserved.
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