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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  HUDSON
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5316
File No.  589
Registered No: 1 
2.	FULL NAME: SHELBY F. COLLARD 
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE: WHITE 
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED: SINGLE 
6.	DATE OF BIRTH: MARCH 10, 1895 
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 17YRS 9MOS 29DS 
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KY
10.	NAME OF FATHER: JAMES H. COLLARD 
11.	BIRTHPLACE OF FATHER: KY 
12.	MAIDEN NAME OF MOTHER: MARY MERCER 
13.	BIRTHPLACE OF MOTHER: KY 
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) JOHN W. COLLARD 
(Address) HARDIN SPRINGS KY 
15.	Filed  1/29/1913
REGISTAR:  JH COMER
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: JAN 9, 1913  
17.	I HEREBY CERTIFY, That I attended deceased from (date): JAN 5, 1913 TO JAN 8, 1913 
That I last saw him/her alive on (date): JAN 8, 1913
And that death occurred on the date stated above at (time AM/PM):  6 AM
THE CAUSE OF DEATH was as follows:  
HOOK WORM
(Duration)   Years:            Months:            Days:  
Contributory: CHOREA  

(Duration)   Years:            Months:   10       Days:  
Signed (M.D.):  J.G. HALE
Date:  
Address:  HARDIN SPRINGS, 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: MT. HEBRON 
DATE OF BURIAL:  JAN 10, 1913
20.	UNDERTAKER:  ALVIN DRANE
ADDRESS:  HARDIN SPRINGS, KY


ADDITIONAL COMMENTS/NOTES:




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