1. PLACE OF DEATH County: BRECKINRIDGE Vot. Pol.: BIG SPRING Inc Town: City: No. St. Ward: Registration District No.: 5314 Primary Registration District No: 14 File No. 22926 Registered No: 23 2. FULL NAME: MILBURN, DORA MAY PERSONAL AND STATICAL PARTICULARS 3. SEX: FEMALE 4. COLOR OR RACE: WHITE 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 6. DATE OF BIRTH: SEPT. 10, 1914 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 5 DA 8. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: KY 10. NAME OF FATHER: CLAUDE MILBURN 11. BIRTHPLACE OF FATHER: KY 12. MAIDEN NAME OF MOTHER: EDNEY HORVELL 13. BIRTHPLACE OF MOTHER: IN 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) CLAUDE MILBURN (Address) CUSTER, KY 15. Filed SEPT. 20, 1914 REGISTRAR: J. L. MORRIS MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: SEPT. 15, 1914 17. I HEREBY CERTIFY, That I attended deceased from (date): SEPT. 12, 1914 That I last saw him/her alive on (date): SEPT. 14, 1914 And that death occurred on the date stated above at (time AM/PM): 3 PM THE CAUSE OF DEATH was as follows: PERIVERTICLE (?) (Duration) Years: Months: Days: Contributory: RECTAL TROUBLE (Duration) Years: Months: Days: Signed (M.D.): R. W. MEADOR Date: Address: CUSTER, 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: DATE OF BURIAL: 20. UNDERTAKER: ADDRESS: