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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  4
Registration District No.:  130
Primary Registration District No:  5304
File No.  9445
Registered No:  
2.	FULL NAME:  Annie Morris Basham
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  Female
4.	COLOR OR RACE:  White
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6.	DATE OF BIRTH:  Aug 23, 1908
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  6 yrs  7 mos  28 ds
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  at home
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  Kentucky
10.	NAME OF FATHER:  Sanford Basham
11.	BIRTHPLACE OF FATHER:  Kentucky
12.	MAIDEN NAME OF MOTHER:  Cynthia Condor
13.	BIRTHPLACE OF MOTHER:  Kentucky
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Master Basham
(Address)  Harned, Ky
15.	Filed  Apr 23, 1914
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  April 22, 1914
17.	I HEREBY CERTIFY, That I attended deceased from (date):  June 1912 to April 22, 1914
That I last saw him/her alive on (date):  June 1913
And that death occurred on the date stated above at (time AM/PM):  3 p.m.
THE CAUSE OF DEATH was as follows:  Potts Disease

(Duration)   Years:            Months:  10          Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  John E. Kincheloe, M.D.
Date:  April 22, 1914
Address:  Hardinsburg
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:  A. N. Skillman farm
DATE OF BURIAL:  April 23, 1914
20.	UNDERTAKER:  B. F. Beard & Co.
ADDRESS:  Hardinsburg


ADDITIONAL COMMENTS/NOTES:




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