1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Custer
Inc Town:
City:
No.
St.
Ward
Registration District No.: 5315
Primary Registration District No:
File No. 16555
Registered No: 29
1. FULL NAME: Jacob Van Meter Milburne
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: September 28, 1912
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 64yrs9mos22ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Hardin Co, Ky
9. NAME OF FATHER: George Milburne
10. BIRTHPLACE OF FATHER: Washington Co, Ky
11. MAIDEN NAME OF MOTHER: Mahala Van Meter
12. BIRTHPLACE OF MOTHER: Hardin Co, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Joe Milburne
(Address) Custer, Ky
14. Filed July 22, 1912
REGISTAR: R.O.Penick
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: July 20, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): May 24, 1912 to July 20, 1912
That I last saw him/her alive on (date): July 20, 1912
And that death occurred on the date stated above at (time AM/PM): 2PM
THE CAUSE OF DEATH was as follows:
Acute yellow atrophy if liver
(Duration)
Years:
Months: 2
Days:
Signed (M.D.): J.W. Meador
Date: July 22, 1912
Address: Custer, 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: Yard Hope
DATE OF BURIAL: July 21, 1912
19. UNDERTAKER: J.T. Mitcham
ADDRESS: Custer, Ky