1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  
Inc Town:  UNION STAR, KY
City:  
No.  
St.  
Ward:
Registration District No.:  5309
Primary Registration District No:  9
File No.  27964
Registered No: 14 
2. FULL NAME:  MILLER, JACOB
PERSONAL AND STATICAL PARTICULARS
3. SEX:  MALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  OCT. 20, 1888
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  26 YR 0 MO 19 DA
8. OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  LODIBURG, KY
10. NAME OF FATHER:  WARREN MILLER
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  ELLEN BAYSINGER
13. BIRTHPLACE OF MOTHER:  LODIBURG, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  FRANK MILLER
(Address)  LODIBURG, KY
15. Filed  NOV 10, 1914
REGISTRAR:  MRS. SUE JOLLY
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  NOV. 9, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  JAN. 1914
That I last saw him/her alive on (date):  NOV. 4, 1914
And that death occurred on the date stated above at (time AM/PM):  11 PM
THE CAUSE OF DEATH was as follows:  
TUBERCULOSIS OF LUNGS
(Duration)   Years:     1       Months:           Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  S. P. PARKS
Date:  NOV. 10, 1914
Address:  IRVINGTON, 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:  WALNUT GROVE
DATE OF BURIAL:  NOV. 11, 1914
20. UNDERTAKER:  G. T. MARSHALL AND SON
ADDRESS:  IRVINGTON, KY