1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Rock Vale
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5320
File No.  21648
Registered No:  5320
2. FULL NAME:  Lillie Ann Weedman
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  June 2, 1912
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  3 mos  9 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Ky
10. NAME OF FATHER:  Joe D Weedman
11. BIRTHPLACE OF FATHER:  Ky
12. MAIDEN NAME OF MOTHER:  Lavinna Abagahs Doroughty
13. BIRTHPLACE OF MOTHER:  Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Pete V. Doroughty
(Address)  Glen Dean, Ky
15. Filed  Sept. 12, 1912
REGISTAR:  J. D. McDonogh
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Sept. 11, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Sept. 6, 1912 to Sept. 11, 1912
That I last saw him/her alive on (date):  Sept. 11, 1912
And that death occurred on the date stated above at (time AM/PM):  11 a.m.
THE CAUSE OF DEATH was as follows:  Acute Ileocolitis

(Duration)   Years:            Months:            Days:  5
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P. E. Dempster, M.D.
Date:  
Address:  Glen Dean, 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:  Robertson Grave Yard
DATE OF BURIAL:  Sept. 12, 1912
20. UNDERTAKER:  H. Wilson 
ADDRESS:  Glen Dean, Ky