1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Glen Dean Ky
Inc Town: Glen Dean Ky
City:
No. 5319
St.
Ward
Registration District No.: 132
Primary Registration District No:
File No. 30164
Registered No:
1. FULL NAME: Josie Moorman
PERSONAL AND STATICAL PARTICULARS
2. SEX: female
3. COLOR OR RACE: negro
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: March 10, 1858
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 53yrs8mos13ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: house keeper
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Ky
9. NAME OF FATHER: Bill Riley
10. BIRTHPLACE OF FATHER: Ky
11. MAIDEN NAME OF MOTHER: Harriett Dean
12. BIRTHPLACE OF MOTHER: Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Lig. Moorman
(Address) 
14. Filed Nov 25, 1911
REGISTAR: E.L. Robertson
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Nov 23, 1911
16. I HEREBY CERTIFY, That I attended deceased from (date): Sept 18, 1911 to Nov 23, 1911
That I last saw him/her alive on (date): Nov 22, 1911
And that death occurred on the date stated above at (time AM/PM): 2 AM
THE CAUSE OF DEATH was as follows:
Tuberculosis
(Duration)
Years:
Months:
Days:
Signed (M.D.): PE Dempster
Date: Nov 24, 1911
Address: Glen Dean, Ky
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: Eli Deans
DATE OF BURIAL: Nov 23, 1911 (could be 24 or 25—numbers written on top of)
19. UNDERTAKER: Wilson Owen & Co
ADDRESS: Glen Dean