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1.	PLACE OF DEATH
County: BRECKINRIDGE 
Vot. Pol.:  HARDINSBURG
Inc Town:  
City:  
No.  
St.  
Ward:  2
Registration District No.:  130
Primary Registration District No: 5304 
File No.  15005
Registered No:  
2.	FULL NAME: EDWARD HAYNES  
PERSONAL AND STATICAL PARTICULARS
3.	SEX: MALE 
4.	COLOR OR RACE: WHITE  
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6.	DATE OF BIRTH: JUNE 7, 1913 
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 3HRS 13MIN 
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed: INFANT  
9.	BIRTHPLACE: KENTUCKY 
10.	NAME OF FATHER: ANDREW HAYNES 
11.	BIRTHPLACE OF FATHER:  KENTUCKY
12.	MAIDEN NAME OF MOTHER:  VIOLET McCUBBINS
13.	BIRTHPLACE OF MOTHER: KENTUCKY 
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  
(Address)  
15.	Filed  JUNE 8, 1913
REGISTAR:  WB LENNON
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: JUNE 7, 1913 
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  
PREMATURE BIRTH
(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.): JNO E. KINCHELOE 
Date:  JUNE 8, 1913
Address: HARDINSBURG, 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:  JUNE 8, 1913
20.	UNDERTAKER:  I.B. RICHARDSON
ADDRESS:  GARFIELD, KY


ADDITIONAL COMMENTS/NOTES:




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