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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5301
File No.  23677
Registered No:  
2.	FULL NAME:  Thomas Miller
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Male
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6.	DATE OF BIRTH:  July 28, 1913
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  1 mos  7 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  Infant
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Kentucky
10.	NAME OF FATHER:  Thomas Miller
11.	BIRTHPLACE OF FATHER:  Kentucky
12.	MAIDEN NAME OF MOTHER:  Lila Jolly
13.	BIRTHPLACE OF MOTHER:  Kentucky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Luthor Lyons
(Address)  McQuady, Ky
15.	Filed  Sept 5, 1913
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  Sept 4, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  Sept 3, 1913 to Sept 4, 1913
That I last saw him/her alive on (date):  Sept. 4, 1913
And that death occurred on the date stated above at (time AM/PM):  4 p.m.
THE CAUSE OF DEATH was as follows:  Labor Pneumonia

(Duration)   Years:            Months:            Days:  1
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Jno E. Kincheloe, M.D.
Date:  Sept 4, 1913
Address:  Hardinsburg, 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:  St. Marys of the Woods
DATE OF BURIAL:  Sept 5, 1913
20.	UNDERTAKER:  B. F. Beard & Co.
ADDRESS:  Hardinsburg, Ky


ADDITIONAL COMMENTS/NOTES:




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