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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  5307
Inc Town:  
City:  CLOVERPORT
No.  
St.  
Ward:  
Registration District No.:  131
Primary Registration District No:  2065
File No.  28692
Registered No: 127 
2.	FULL NAME:  ROBERTSON, MOLLIE M. MILLER
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  COLORED
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  MAR 4, 1874
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  39 / 8 / 7 
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  H0USE WORK
(b.)  General nature of industry business or establishment which employed:  GENERAL HOUSE WORK
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  GEORGE MILLER
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  DEALIA MOORMAN
13.	BIRTHPLACE OF MOTHER:  KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  G.W. ROBERTSON
(Address)  CLOVERPORT
15.	Filed  NOV 11, 1913
REGISTAR:  J.C. NOLTE
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  NOV 10, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  NOV 9, 1913 to NOV 10, 1913
That I last saw him/her alive on (date):  NOV 10, 1913
And that death occurred on the date stated above at (time AM/PM):  10:45 PM
THE CAUSE OF DEATH was as follows:  CEREBRAL HEMMORHAGE
(Duration)   Years:            Months:            Days:    1
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E.C. MCDONALD
Date:  NOV 11, 1913
Address:  CLOVERPORT
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
DATE OF BURIAL:  NOV 12, 1913
20.	UNDERTAKER:  M. HAMMAN & SONS
ADDRESS:  CLOVERPORT


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

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