1. PLACE OF DEATH County: Breckinridge Vot. Pol.: Custer Inc Town: City: No. St. Ward: Registration District No.: 5315 Primary Registration District No: File No. 27051 Registered No: 2. FULL NAME: Haynes, Dannie PERSONAL AND STATICAL PARTICULARS 3. SEX: Male 4. COLOR OR RACE: White 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single 6. DATE OF BIRTH: Apr 27, 1896 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 16 yr 6 mo 17 da 8. OCCUPATION (a.) Trade, profession or particular kind of work: Farmer (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Garfield, KY 10. NAME OF FATHER: George Haynes 11. BIRTHPLACE OF FATHER: Garfield, KY 12. MAIDEN NAME OF MOTHER: Della Springate 13. BIRTHPLACE OF MOTHER: Garfield, KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) J. W. Webb (Address) Garfield, KY 15. Filed Nov. 24, 1912 REGISTRAR: J. T. Mitcham MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: Nov. 14, 1912 17. I HEREBY CERTIFY, That I attended deceased from (date): Jan. 14, 1912 That I last saw him/her alive on (date): Oct. 21. 1912 And that death occurred on the date stated above at (time AM/PM): 3 am THE CAUSE OF DEATH was as follows: Pulmonary tuberculosis (Duration) Years: Months: 11 Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): J. A. Sandbach Date: Nov. 14, 1912 Address: Garfield, 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: Freedom Cemetery DATE OF BURIAL: Nov. 15, 1912 20. UNDERTAKER: I. B. Richardson ADDRESS: Garfield, KY