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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.  26150
Registered No:  
2.	FULL NAME:  JOHNSON, MARY
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  OCT 14, 1913
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):   1 DAY, 12 HRS
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  GARFIELD, BRECKINRIDGE, KY
10.	NAME OF FATHER:  PIUS JOHNSON
11.	BIRTHPLACE OF FATHER:  GARFIELD
12.	MAIDEN NAME OF MOTHER:  ANNIE MEADOR
13.	BIRTHPLACE OF MOTHER:  GARFIELD
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  PIUS JOHNSON
(Address)  GARFIELD
15.	Filed  OCT 16, 1913
REGISTAR:  W.B. LEMMON
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  OCT 15, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  OCT 14, 1913 to OCT 16, 1916
That I last saw him/her alive on (date):  OCT 16, 1913
And that death occurred on the date stated above at (time AM/PM):  6 PM
THE CAUSE OF DEATH was as follows:  PREMATURE BIRTH
(Duration)   Years:            Months:            Days:     1 1/2 DAYS
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E.C. HARNED
Date:  OCT 16, 1913
Address:  GARFIELD
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:  JOHNSON CEMETERY
DATE OF BURIAL:  OCT 16, 1913
20.	UNDERTAKER:  J.B. RICHARDSON
ADDRESS:  GARFIELD


ADDITIONAL COMMENTS/NOTES:




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