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: