1.  PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  2
Registration District No.:  5302
Primary Registration District No:  
File No.  17180
Registered No:  40 
2.  FULL NAME:  Carl Haynes
PERSONAL AND STATICAL PARTICULARS
3.  SEX:  Male
4.  COLOR OR RACE:  White
5.  SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6.  DATE OF BIRTH:  12-19-1910
7.  AGE  (yr. mo. da) (If less than 1 day, hours or min?):  6 mos 18 days
8.  OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9.  BIRTHPLACE:  Louisville, Ky City Hospital
10.  NAME OF FATHER:  Aaron Hardin Haynes
11.  BIRTHPLACE OF FATHER:  Breckinridge Co, Ky
12.  MAIDEN NAME OF MOTHER:  Lola Hook
13.  BIRTHPLACE OF MOTHER:  Breckinridge Co, Ky
14.  THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  H. W. Basham
(Address)  Hardinsburg, Ky
15.  Filed  July 8, 1911
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16.  DATE OF DEATH:  7-8-1911
17.  I HEREBY CERTIFY, That I attended deceased from (date):  Jun 30, 1911 to July 8, 1911
That I last saw him alive on (date):  July 2, 1911
And that death occurred on the date stated above at (time AM/PM):  2 pm
THE CAUSE OF DEATH was as follows:  Enterocolitis following measels in Louisville Ky: and Enterocolitis 2 weeks in same place

(Duration)   Years:            Months:            Days:  7
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  A. M. Kincheloe
Date:  7-8-1911
Address:  Hardinsburg, Ky
18.  LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)
At place of death (yr, mo, da.):  9 days
In the State (yr, mo, da):  6 months, 18 days
Where was disease contracted,  if not at place of death?  Louisville, Ky
Former or usual residence:  Breckinridge, Co, Ky
19.  PLACE OF BURIAL OR REMOVAL:  Freedom Cemetery
DATE OF BURIAL:  July 9, 1911
20.  UNDERTAKER:  Robt Weatherford
ADDRESS:  Harnel, Ky