1.       PLACE OF DEATH

County: Breckinridge    

Vot. Pol.: Burbey Hills

Inc Town: 

City:

No. 5313

St.

Ward

Registration District No.: 

Primary Registration District No:

File No. 20137

Registered No: 7

2.       FULL NAME: Millie Marie Haynes

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: White

5.       SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single

6.       DATE OF BIRTH: Aug 11, 1911

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 

8.       OCCUPATION (a.) Trade, profession or particular kind of work: Lived with parents

(b.)  General nature of industry business or establishment which employed:

9.       BIRTHPLACE: Garfield KY Breck Co.

10.   NAME OF FATHER: Avery Haynes

11.   BIRTHPLACE OF FATHER: Garfield KY Breck Co.

12.   MAIDEN NAME OF MOTHER: Cilla Meador

13.   BIRTHPLACE OF MOTHER: Garfield KY Breck Co.

14.   THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant) A. H. Haynes

(Address) Garfield KY

15.   Filed Aug 8, 1911

REGISTAR: John Compton

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: Aug 3, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date): Aug 2, 1911 to Aug 3, 1911

That I last saw him/her alive on (date): Aug 3, 1911

And that death occurred on the date stated above at (time AM/PM): 3 AM

THE CAUSE OF DEATH was as follows: Congenital Dability caused by Ansomnia in mother

CONTRIBUTORY: unreadable 

(Duration)

Years:

Months:

Days:

Signed (M.D.): J.A. Sandbach

Date: Aug 3, 1911

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

DATE OF BURIAL:

20.   UNDERTAKER:

ADDRESS:

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