1. PLACE OF DEATH County: Breckinridge Vot. Pol.: 5307 Inc Town: Cloverport, City: No. St. Ward: 3rd Registration District No.: 131 Primary Registration District No: 2065 File No. 27038 Registered No: 76 1. FULL NAME: Thomas Lewis PERSONAL AND STATICAL PARTICULARS 2. SEX: male 3. COLOR OR RACE: white 4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married 5. DATE OF BIRTH: Feby 8, 1836 6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 79yrs10mos29ds 7. OCCUPATION (a.) Trade, profession or particular kind of work: carpenter (b.) General nature of industry business or establishment which employed: general wood work 8. BIRTHPLACE: Kentucky 9. NAME OF FATHER: Thos. Lewis 10. BIRTHPLACE OF FATHER: Virginia 11. MAIDEN NAME OF MOTHER: Polly Mattingly 12. BIRTHPLACE OF MOTHER: Kentucky 13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Florence Lewis (Address) Cloverport, Ky 14. Filed Nov 7, 1912 REGISTAR: JC Nolte MEDICAL CERTIFICATE OF DEATH 15. DATE OF DEATH: November 7, 1912 16. I HEREBY CERTIFY, That I attended deceased from (date): Nov 6, 1912 to Nov 7, 1912 That I last saw him/her alive on (date): Nov 7, 1912 And that death occurred on the date stated above at (time AM/PM): 11:30 AM THE CAUSE OF DEATH was as follows: Apoplexy (Duration) Years: Months: Days: 1 Contributory: Arterio-Sclerosis…………….5 years Signed (M.D.): F.L. Lightfoot Date: Nov 8, 1912 Address: Cloverport, 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: Hardinsburg, Breckinridge Co, Ky DATE OF BURIAL: Nov 8, 1912 19. UNDERTAKER: M Hamman Sons ADDRESS: Cloverport, Ky