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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  BEWLEYVILLE
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5313
File No.  15842
Registered No:  
2.	FULL NAME:  DEHAVEN, ELLEN
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  COLORED
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  
6.	DATE OF BIRTH:  MAY 30, 1840
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  75 / 1 / --
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEKEEPING
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KENTUCKY
10.	NAME OF FATHER:  COULD NOT ASCERTAIN
11.	BIRTHPLACE OF FATHER:  
12.	MAIDEN NAME OF MOTHER: NO WAY TO FIND OUT 
13.	BIRTHPLACE OF MOTHER:  UNKNOWN
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  P.W. FOOTE
(Address)  IRVINGTON
15.	Filed  JUL 1, 1915
REGISTAR:  JAKE --------
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  JUN 30, 1915
17.	I HEREBY CERTIFY, That I attended deceased from (date):  MERELY MEDICAL ADVISOR
That I last saw him/her alive on (date):  JUN 20, 1915
And that death occurred on the date stated above at (time AM/PM):  3 PM
THE CAUSE OF DEATH was as follows:  SENILITY - SHE LIKELY DIED WITHOUT CALLING A DOCTOR LIKE MANY OF THESE OLD SLAVES DO
(Duration)   Years:            Months:            Days:    
Contributory:  
(Duration)   Years:            Months:            Days:  
Signed (M.D.): P.W. FOOTE 
Date:  JUL 1, 1915
Address:  IRVINGTON
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:  NO INFORMATION PROVIDED
DATE OF BURIAL:  
20.	UNDERTAKER:  
ADDRESS:  


ADDITIONAL COMMENTS/NOTES:




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