PERSONAL AND STATISTICAL PARTICULARS
1. Place of death: City Hospital
2. Full name: Lula Baucum
3. Sex: F
4. Color or race: W
5. Single, married, widowed, or divorced: S
6. Date of birth: Apr. 10, 1916
7. Age: 5 mos.
8. Occupation: None
9. Birthplace: Tenn.
10. Name of father: O.H. Tabb
11. Birthplace: Tenn.
12. Maiden name of mother: Mattie Lee Baucum
13. Birthplace of mother: Tenn.
14. The above is true to the best of my knowledge: [Informant] L.E. Pender, Address: Hospital

MEDICAL CERTIFICATE OF DEATH
16. Date of death: Sept. 11, 1916
17. I HEREBY CERTIFY, That I attended deceased from Sept. 6, 1916, to September 11, 1916, that I last saw her alive on Sept. 11, 1916, and that death occurred on the date stated above at 3:25 pm.
The cause of death was as follows: Malnutrition
Contributory: Artificial feeding
18. Where was disease contracted, if not at place of death?: St. Peters Orphanage
Former or usual residence: St. Peters Orphanage