1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  3
Registration District No.:  5303
Primary Registration District No:  
File No.  246
Registered No:  5
2. FULL NAME:  STILLBORN
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Jan. 29, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  0 yr 0 mo 0 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., KY
10. NAME OF FATHER:  Frank Macy
11. BIRTHPLACE OF FATHER:  Breckinridge Co, KY
12. MAIDEN NAME OF MOTHER:  Mary May Wheatly
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Grant Dennis
(Address)  Hardinsburg, KY
15. Filed  Jan. 30, 1911
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Jan. 29, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  Stillborn

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. C. Sutton
Date:  Jan. 30, 1911
Address:  Hardinsburg, KY
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:  St. Romauld's Church
DATE OF BURIAL:  Jan. 30, 1911
20. UNDERTAKER:  None
ADDRESS: