1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Glen Dean
Inc Town: Glen Dean
City:
No. 5319
St.
Ward
Registration District No.: 132
Primary Registration District No:
File No. 30087
Registered No:
1. FULL NAME: Henry Priest Moorman
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Jan 27, 1853
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 58yrs9mos19ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Owensboro, Ky
9. NAME OF FATHER: Henry Moorman
10. BIRTHPLACE OF FATHER: Daviess Co, Ky
11. MAIDEN NAME OF MOTHER: Mary Priest
12. BIRTHPLACE OF MOTHER: Jefferson Co, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) M.R. Moorman
(Address) Glen Dean, Ky
14. Filed Oct 28, 1911
REGISTAR: E.L. Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Oct 26, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Sept 15, 1911 to Oct 26, 1911
That I last saw him/her alive on (date): Oct 26, 1911
And that death occurred on the date stated above at (time AM/PM): 2PM
THE CAUSE OF DEATH was as follows:
Chronic Gastritis
Contributory: “Perhaps” enlargement of Liver
(Duration)
Years: 4
Months:
Days:
Signed (M.D.): R.T. Dempster
Date: Oct 27, 1911
Address: Glen Dean
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: Glen Dean
DATE OF BURIAL: Oct 27, 1911
19. UNDERTAKER: B.F. Beard & Co
ADDRESS: Hardinsburg Ky