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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  CUSTER
Inc Town:  CUSTER
City:  
No.  
St.  
Ward:  
Registration District No.: 5315 
Primary Registration District No: 15 
File No.  21026 STAMPED ABOVE 58
Registered No:  58
2.	FULL NAME:  NANCY CATHERINE HAYNES
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE: WHITE   
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH: OCTOBER 16, 1847 
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 65YRS 2MOS 8DS 
8.	OCCUPATION (a.) Trade, profession or particular kind of work: AT HOME  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE CO KY
10.	NAME OF FATHER:  ANDREW J MARRS
11.	BIRTHPLACE OF FATHER: GREEN CO, KY 
12.	MAIDEN NAME OF MOTHER: MARY ANN SHADWIN (Chaudoin)
13.	BIRTHPLACE OF MOTHER:  BRECKINRIDGE CO, KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) JAMES HAYNES 
(Address) CUSTER, KY 
15.	Filed  AUG 88, 1913
REGISTAR:  J.T. MITCHAM
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: AUGUST 8, 1913 
17.	I HEREBY CERTIFY, That I attended deceased from (date):  APR 8, 1912 TO AUG 8, 1913
That I last saw her alive on (date): AUG 8, 1913 
And that death occurred on the date stated above at (time AM/PM): 12 
THE CAUSE OF DEATH was as follows:  
TUBERCULOSIS OF LUNGS
(Duration)   Years:            Months:            Days:  
Contributory:  RHUMATISM

(Duration)   Years: 2           Months:            Days:  
Signed (M.D.): J.W. MEADOR 
Date:  
Address: CUSTER, 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: MARR B. GR. 
DATE OF BURIAL:  AUG 8, 1913
20.	UNDERTAKER: ALF TAYLOR 
ADDRESS: CUSTER, KY 


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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