1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Stephensport
Inc Town: Stephensport, Ky
City:
No.
St.
Ward
Registration District No.:
Primary Registration District No: 5308
File No. 14341
Registered No: 20
1. FULL NAME: Still Birth
PERSONAL AND STATICAL PARTICULARS
2. SEX: boy
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED:
5. DATE OF BIRTH:
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?):
7. OCCUPATION (a.) Trade, profession or particular kind of work:
(b.)  General nature of industry business or establishment which employed:
8. BIRTHPLACE:
9. NAME OF FATHER:
10. BIRTHPLACE OF FATHER:
11. MAIDEN NAME OF MOTHER:
12. BIRTHPLACE OF MOTHER:
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
14. Filed June 7, 1912
REGISTAR: RA Shellman
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: 6-5-1912
16. I HEREBY CERTIFY, That I attended deceased from (date):
That I last saw him/her alive on (date): 6-5-1912
And that death occurred on the date stated above at (time AM/PM): 1AM
THE CAUSE OF DEATH was as follows:
Still borned
(Duration)
Years:
Months:
Days:
Signed (M.D.): Geo E Shively
Date: 6/5/1912
Address: Stephensport, 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: Stephensport
DATE OF BURIAL: June 5, 1912
19. UNDERTAKER: WJ Schopp
ADDRESS: Stephensport, Ky


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