1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Mooleyville, KY
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5310
Primary Registration District No:  
File No.  238
Registered No:  68
2. FULL NAME:  Vessels, Burnard Lee
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Jan 24 1912
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  Stillborn
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., KY
10. NAME OF FATHER:  R. A. Vessels
11. BIRTHPLACE OF FATHER:  Kansas
12. MAIDEN NAME OF MOTHER:  Kattie Tobin
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  
(Address)  
15. Filed  Jan. 31 1912
REGISTRAR:  J. D. Cunningham
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Jan 24 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jan 24 1912
That I last saw him/her alive on (date):  never, stillborn
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  Placenta ??

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  William L. Milner
Date:  Jan 24 1912
Address:  Union Star, KY
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:  
DATE OF BURIAL:  
20. UNDERTAKER:  
ADDRESS:  

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