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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  #8
Inc Town:  STEPHENSPORT
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5308
File No.  12324
Registered No: 52 
2.	FULL NAME:  HORSLEY, WILLIAM A.
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  NOT LISTED
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  35 / 0 / 0 
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  JOHN HORSLEY
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  JANE CARMAN
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  LEE STEWART
(Address)  UNION STAR
15.	Filed  	MAY 12, 1914
REGISTAR:  R.A. SHELLMAN
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  MAY 10, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  MAY 10, 1914 to MAY 10, 1914
That I last saw him/her alive on (date):  MAY 2, 1914
And that death occurred on the date stated above at (time AM/PM):  2 PM
THE CAUSE OF DEATH was as follows:  IMMEDIATE - GUNSHOT WOUND
(Duration)   Years:            Months:            Days:    
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  GEORGE E. SHIVELY
Date:  MAY 12, 1914
Address:  STEPHENSPORT
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:  SAMPLE, KY
DATE OF BURIAL:  MAY 12, 1914
20.	UNDERTAKER:  C.A. TINIUS
ADDRESS:  STEPHENSPORT


ADDITIONAL COMMENTS/NOTES:




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