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1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  MCDANIELS
Inc Town:  
City:  
No.  
St.  
Ward:
Registration District No.:  5318
Primary Registration District No:  
File No.  22931
Registered No:  
2. FULL NAME:  HAYES, RUSSELL
PERSONAL AND STATICAL PARTICULARS
3. SEX:  MALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6. DATE OF BIRTH:  
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  24 DS
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  BRECKINRIDGE
10. NAME OF FATHER:   	JOSEPH HAYES
11. BIRTHPLACE OF FATHER:  BRECKINRIDGE
12. MAIDEN NAME OF MOTHER:  MARY PARSONS
13. BIRTHPLACE OF MOTHER:  BRECKINRIDGE
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  H. J. HAYES
(Address)  WEST VIEW, KY
15. Filed  SEPT. 15, 1914
REGISTRAR:  M. M. JARBOE
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  SEPT. 15, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  AUG. 20, 1914
That I last saw him/her alive on (date):  SEPT. 6, 1914
And that death occurred on the date stated above at (time AM/PM):  9 AM
THE CAUSE OF DEATH was as follows:  CHRONIC DIARRHEA

(Duration)   Years:            Months:      2     Days:  10
Contributory:  MALNUTRITION

(Duration)   Years:            Months:      1      Days:  10
Signed (M.D.):  J. C. TUCKER
Date:  SEPT. 5, 1914
Address:  MCDANIELS, 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:  
DATE OF BURIAL:  
20. UNDERTAKER:  
ADDRESS: