1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: 5307
Inc Town: Cloverport, Ky
City:
No.
St.
Ward: 3rd
Registration District No.: 131
Primary Registration District No: 5307
File No. 19021
Registered No: 71
1. FULL NAME: Arthur Miller
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: colored
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: November 15, 1882
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 29yrs8mos26ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: Day laborer
(b.)  General nature of industry business or establishment which employed: last worked at rock crusher
8. BIRTHPLACE: Kentucky
9. NAME OF FATHER: Geo. Miller
10. BIRTHPLACE OF FATHER: Kentucky
11. MAIDEN NAME OF MOTHER: Cornelia Moorman
12. BIRTHPLACE OF MOTHER: Kentucky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Geo Miller
(Address) Cloverport, Ky
14. Filed Aug 11, 1012
REGISTAR: JC Nolte
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Aug 11, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Aug 11, 1912 to Aug 11, 1912
That I last saw him/her alive on (date): Aug 11, 1912
And that death occurred on the date stated above at (time AM/PM): 2AM
THE CAUSE OF DEATH was as follows:
Rail road accident (presumed to be asleep on track)
(Duration)
Years:
Months:
Days:
Contributory: alcoholic intoxication
Signed (M.D.): A.A. Simons
Date: Aug 13, 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: Cloverport, Ky
DATE OF BURIAL: Aug 11, 1912
19. UNDERTAKER: M Hamman Sons
ADDRESS: Cloverport, Ky