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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  ROCK VALE
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5320
Primary Registration District No:  
File No.  9463   [DUPLICATE - ORIGINAL LOST]
Registered No:  
2.	FULL NAME:  JOHNSON, PAULINE
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  FEB 24, 1914
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:  BRECKINRIDGE
10.	NAME OF FATHER:  BEN JOHNSON
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  ETHEL MARLOW   [GIVEN NAME SMEARED]
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  BEN JOHNSON
(Address)  VANZANDT
15.	Filed  APR 6, 1914
REGISTAR:  J.D. McDONOUGH
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  APR 6, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  APR 6, 1914
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  PNEUMONIA
(Duration)   Years:            Months:            Days:    
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E.P. ROGERS
Date:  MAY 11, 1914
Address:  FORDSVILLE
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:  CHANCELLOR GRAVEYARD
DATE OF BURIAL:  APR 7, 1914
20.	UNDERTAKER:  
ADDRESS:  


ADDITIONAL COMMENTS/NOTES:




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