1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  4
Inc Town:  Hardinsburg, Ky
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5304
File No.  247
Registered No:  3
2. FULL NAME:  Mary Jane Tate
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widowed
6. DATE OF BIRTH:  Sept. 3, 1829
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  81 yrs  4 mos  4 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Had none
(b.)  General nature of industry business or establishment which employed:  At House
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Henry Miller
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Emma Lay
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Monroe Hook
(Address)  Hardinsburg, Ky
15. Filed  Jan 8, 1911
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Jan 7, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  April 13, 1910 to Jan 7, 1911
That I last saw him/her alive on (date):  July 28, 1910
And that death occurred on the date stated above at (time AM/PM):  11 p.m.
THE CAUSE OF DEATH was as follows:  Chronic Intestinal Nephritis

(Duration)   Years:            Months:  8          Days:  25
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  Jno. E. Kincheloe, M.D.
Date:  Jan. 8, 1911
Address:  
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:  Henry Miller Cemetery
DATE OF BURIAL:  Jan., 1911
20. UNDERTAKER:  Jno T. Hoben
ADDRESS:  Hardinsburg

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