1. PLACE OF DEATH
County:Breckinridge
Vot. Pol.: McDaniels
Inc Town:
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5318
File No. 27054
Registered No:
1. FULL NAME: Willie Morris
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: single
5. DATE OF BIRTH: Nov 19, 1912
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 4hrs
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE: Breckinridge Co
9. NAME OF FATHER: Allen B Morris
10. BIRTHPLACE OF FATHER: Breckinridge Co, Ky
11. MAIDEN NAME OF MOTHER: Maggie M. Gannaway
12. BIRTHPLACE OF MOTHER: Breckinridge Co, Ky
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  unsigned
(Address)
14. Filed Nov 20, 1912
REGISTAR: M.M. Jarboe
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: Nov 19, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Nov 19, 1912 to Nov 19, 1912
That I last saw him/her alive on (date): Nov 19, 1912
And that death occurred on the date stated above at (time AM/PM): 7:40 PM
THE CAUSE OF DEATH was as follows:
Umbilical Hemorrhage
(Duration)
Years:
Months:
Days: 4 hours
Signed (M.D.): J.B. Lampton
Date: Nov 19, 1912
Address: McDaniels, 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
DATE OF BURIAL:
19. UNDERTAKER:
ADDRESS: