1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  5007
Inc Town:  CLOVERPORT, KY
City:  
No.  
St.  
Ward: 3
Registration District No.:  131
Primary Registration District No:  3
File No.  30820
Registered No: 179 
2. FULL NAME:  MOAD, HARRIET
PERSONAL AND STATICAL PARTICULARS
3. SEX:  FEMALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6. DATE OF BIRTH:  APR 22 1896
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  18 YR 8 MO 9 DA
8. OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEKEEPER
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  JAMES TUCKER
11. BIRTHPLACE OF FATHER:  IN
12. MAIDEN NAME OF MOTHER: ANNIE E. PATE
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  HORACE MOAD
(Address)  CLOVERPORT, KY
15. Filed  JAN. 2, 1915
REGISTRAR:  J. C. NOLTE
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: DEC. 31, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  DEC. 30, 1914
That I last saw him/her alive on (date):  DEC. 30, 1914
And that death occurred on the date stated above at (time AM/PM):  10:26 PM
THE CAUSE OF DEATH was as follows:  TUBERCULOSIS OF BOWELS

(Duration)   Years:            Months:   8       Days:  
Contributory:  TUBERCULOSIS DEVELOPED AFTER CHILDBIRTH ABOUT ONE YEAR AGO.

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  F. L. LIGHTFOOT
Date:  JAN. 2, 1915
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:  CLOVERPORT, KY
DATE OF BURIAL:  JAN. 1, 1915
20. UNDERTAKER:  M. HAMMAN AND SON
ADDRESS:  CLOVERPORT, KY