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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  McDANIELS
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5318
File No.  25218
Registered No:  
2.	FULL NAME:  KIPER, MINNIE MAY HORNBACK
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  DEC 19, 1889
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  25 / 9 / 17
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWIFE
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  JAMES W. HORNBACK
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  MAGGIE POTTS
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J.M. KIPER
(Address)  ------ KY
15.	Filed  OCT 7, 1914
REGISTAR:  M.M. JARBOE
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  OCT 6, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  OCT 1, 1914
That I last saw him/her alive on (date):  OCT 1, 1914
And that death occurred on the date stated above at (time AM/PM):  10 PM
THE CAUSE OF DEATH was as follows:  PULMONARY TUBERCULOSIS
(Duration)   Years:    ABT 1        Months:            Days:    
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J.B. LAMPTON
Date:  OCT 7, 1914
Address:  McDANIELS
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:  NO INFORMATION PROVIDED
DATE OF BURIAL:  
20.	UNDERTAKER:  
ADDRESS:  


ADDITIONAL COMMENTS/NOTES:




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