1. 	PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hudson
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.: 5316 
Primary Registration District No:  
File No.  		266
Registered No: 2
2. 	FULL NAME: Died Unnamed
PERSONAL AND STATICAL PARTICULARS
3. 	SEX: Infant Girl
4. 	COLOR OR RACE: White  
5. 	SINGLE, MARRIED, WIDOWED, OR DIVORCED: Infant
6. 	DATE OF BIRTH: Jan 15, 1911
7. 	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 10 days
8. 	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. 	BIRTHPLACE:  
10. 	NAME OF FATHER: Lonnie H Butler
11. 	BIRTHPLACE OF FATHER: Hudson Ky
12. 	MAIDEN NAME OF MOTHER: Affie Keaser
13. 	BIRTHPLACE OF MOTHER: Constantine, Ky
14. 	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 
(Informant) Go Keaser
(Address) Constantine KY
15. 	Filed Jan 27, 1911
REGISTAR: JS Heamer
MEDICAL CERTIFICATE OF DEATH
16. 	DATE OF DEATH: Jan 25, 1911
17. 	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date): at Birth on 15 day Jan, 1911
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows: innutiation

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.): HC Stone
Date: Jan 25, 1911 
Address: Constantine, 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: Coyles Grave Yard  
DATE OF BURIAL: Jan 27, 1911
20. 	UNDERTAKER: Geo Keaser
ADDRESS:  		Constantine, KY