1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  	
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5302
File No.  24209
Registered No: 126 
2. FULL NAME:  Harper, Mary Ruth
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Aug. 11, 1910
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  2 yr 2 mo 2 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:  L. D. Harper
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  Blouise Milan
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  L. D. Harper
(Address)  Westview, KY
15. Filed  Oct. 14, 1912
REGISTRAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Oct. 13, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Oct. 11, 1912
That I last saw him/her alive on (date):  Oct. 13, 1912
And that death occurred on the date stated above at (time AM/PM):  12:40 PM
THE CAUSE OF DEATH was as follows:  Diphtheria

(Duration)   Years:            Months:            Days:  4
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. E. Matthews
Date:  Oct. 13, 1912
Address:  Westview, 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:  Mt. Zion Cemetery
DATE OF BURIAL:  Oct. 14, 1912
20. UNDERTAKER:  Robert Weatherford
ADDRESS:  Harned, KY