1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  5306
Inc Town:  CLOVERPORT, KY
City:  
No.  
St.  
Ward: 2
Registration District No.:  131
Primary Registration District No:  
File No.  3504
Registered No:  158
2. FULL NAME:  MILLER, THOMAS J.
PERSONAL AND STATICAL PARTICULARS
3. SEX:  MALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  JUNE 16, 1866
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  47 YR 8 MO 7 DA
8. OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  MACE MILLER
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  MARY BALL
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  ALLAN MILLER
(Address)  CLOVERPORT, KY
15. Filed  FEB. 28, 1914
REGISTRAR:  J. C. NOLTE
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: FEB 23, 1914 
17. I HEREBY CERTIFY, That I attended deceased from (date):  FEB. 17, 1914
That I last saw him/her alive on (date):  FEB. 19, 1914
And that death occurred on the date stated above at (time AM/PM):  12:30 AM
THE CAUSE OF DEATH was as follows:  ?  ?  TUBERCULOSIS

(Duration)   Years:            Months:     3     Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. C. MCDONALD
Date:  FEB. 28, 1914
Address:  CLOVERPORT, 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:  (JAUL’S) BRECKINRIDGE CO
DATE OF BURIAL:  FEB 24, 1914
20. UNDERTAKER:  M. HAMMAN SONS
ADDRESS:  CLOVERPORT, KY