1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Glen Dean
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5319
File No.
Registered No:
1. FULL NAME: Romie W Jolly
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: May 27, 1912
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 4mos13ds
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Kentucky
9. NAME OF FATHER: Lydal Jolly
10. BIRTHPLACE OF FATHER: Ky
11. MAIDEN NAME OF MOTHER: Georgia Seaton
12. BIRTHPLACE OF MOTHER: Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) E.J. Seaton
(Address) Glendeane
14. Filed Oct 10, 1912
REGISTAR: Mrs M. P. Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Oct 10, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): July 25, 1912 to Oct 10, 1912
That I last saw him/her alive on (date): Oct 10, 1912
And that death occurred on the date stated above at (time AM/PM): 9PM
THE CAUSE OF DEATH was as follows:
Abdominal Tuberculosis
(Duration)
Years:
Months: 4
Days:
Signed (M.D.): PE Dempster
Date: Oct 11, 1912
Address: Glen Dean, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Seaton Grave Yard
DATE OF BURIAL: Oct 11, 1912
19. UNDERTAKER:
ADDRESS: