1. PLACE OF DEATH County: Breckinridge Vot. Pol.: Mooleyville Inc Town: City: No. St. Ward: Registration District No.: 5310 Primary Registration District No: File No. 2.2958 Registered No: 5310 2. FULL NAME: Pearl Hayden PERSONAL AND STATICAL PARTICULARS 3. SEX: Male 4. COLOR OR RACE: White 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single 6. DATE OF BIRTH: Nov 14, 1880 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 21 yrs, 3 mos, 8 days 8. OCCUPATION (a.) Trade, profession or particular kind of work: Farmer (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Mooleyville, Ky 10. NAME OF FATHER: Sidney Hayden 11. BIRTHPLACE OF FATHER: Marion County 12. MAIDEN NAME OF MOTHER: Susan Cox 13. BIRTHPLACE OF MOTHER: Breckinridge, Co. 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Mrs. Susan Hayden (Address) Mooleyville, Ky 15. Filed Feb 23,1911 REGISTAR: Jennie Cunningham MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: Feb 22, 1911 17. I HEREBY CERTIFY, That I attended deceased from (date): Oct 11, 1910 to Feb 17, 1911 That I last saw him alive on (date): Feb 17, 1911 And that death occurred on the date stated above at (time AM/PM): 6 am THE CAUSE OF DEATH was as follows: Tuberculosis Pulmonary (Duration) Years: Months: 4 Days: 11 Contributory: (Duration) Years: Months: Days: Signed (M.D.): D.S. Spire Date: Feb 22, 1911 Address: Mooleyville 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: St. Theresa DATE OF BURIAL: Feb 23, 1911 20. UNDERTAKER: J. C. Manning ADDRESS: Mooleyville