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1.	PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5303
File No.  573
Registered No:  141
2.	FULL NAME:  DE HAVEN, MARY LILA
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  BLACK
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH:  DEC. 27, 1905
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  7 YR 0 MO 9 DA
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KY
10.	NAME OF FATHER:  BEARD DE HAVEN
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  IDA BRADFORD
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  IDA DE HAVEN
(Address)  HARDINSBURG, KY
15.	Filed  JAN 6, 1913
REGISTAR:  W. B. LENNON
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  JAN. 5, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  DEC. 21, 1912
That I last saw him/her alive on (date):  JAN. 4, 1913
And that death occurred on the date stated above at (time AM/PM):  8:20 AM
THE CAUSE OF DEATH was as follows:  TYPHOID FEVER

(Duration)   Years:            Months:            Days:  15
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  JOHN E. KINCHELOE
Date:  JAN. 6, 1913
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:  HARDINSBURG CEMETERY
DATE OF BURIAL:  JAN. 6, 1913
20.	UNDERTAKER:  B. F. BEARD
ADDRESS:  HARDINSBURG, KY


ADDITIONAL COMMENTS/NOTES:




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