1. PLACE OF DEATH County: Breckinridge Vot. Pol.: Mooley Ville Inc Town: City: No. 10 St. Ward Registration District No.: Primary Registration District No: 5310 File No. 9233 Registered No: 5310 1. FULL NAME: Bernard Killim PERSONAL AND STATICAL PARTICULARS 2. SEX: Male 3. COLOR OR RACE: white 4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single 5. DATE OF BIRTH: 6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 7. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 8. BIRTHPLACE: 9. NAME OF FATHER: 10. BIRTHPLACE OF FATHER: 11. MAIDEN NAME OF MOTHER: 12. BIRTHPLACE OF MOTHER: 13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) (Address) 14. Filed Apr 28, 1912 REGISTAR: J.D. Cunningham Per Jennie Cunningham MEDICAL CERTIFICATE OF DEATH 15. DATE OF DEATH: April 26, 1912 16. I HEREBY CERTIFY, That I attended deceased from (date): June(?) 25, 1910 to April 26, 1912 That I last saw him/her alive on (date): April 26, 1912 And that death occurred on the date stated above at (time AM/PM): 9 PM THE CAUSE OF DEATH was as follows: Uremic Coma (Duration) Years: Months: Days: 2 Contributory: Chronic Interstitial Nephritis Signed (M.D.): D.S. Sphire Date: April 27, 1912 Address: Mooleyville 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: St Theresa DATE OF BURIAL: Apr 28, 1912 19. UNDERTAKER: F.E. Yates ADDRESS: Chenault