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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  5307
Inc Town:  Cloverport, Ky
City:  
No.  
St.  
Ward:  3rd
Registration District No.:  131
Primary Registration District No:  
File No.  3589
Registered No:  101
2.	FULL NAME:  Not Names (Still born)
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  male
4.	COLOR OR RACE:  colored
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6.	DATE OF BIRTH:  Feb 27, 1913
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:  Ky (Breckinridge Co.)
10.	NAME OF FATHER:  Allie Howard
11.	BIRTHPLACE OF FATHER:  Kentucky
12.	MAIDEN NAME OF MOTHER:  Lummie Holm
13.	BIRTHPLACE OF MOTHER:  Kentucky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Allie Howard
(Address)  Cloverport, Ky
15.	Filed  Feby 28, 1913
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Feb. 27, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Feb. 27, 1913 to Feb. 27, 1913
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:  Still Born,  premature Birth

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Mary Dean  midwife
Date:  Feb. 28, 1913
Address:  Cloverprt, Ky
attest  C. W. Hamman M.D.
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:  Colored Cemetery
DATE OF BURIAL:  Feb 28, 1913
20.	UNDERTAKER:  M. Hamman Sons
ADDRESS:  Cloverport, Ky


ADDITIONAL COMMENTS/NOTES:




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