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.  2329
Registered No:  
2. FULL NAME:  Haynes, Perlie
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  June 26, 1894
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  17 yr 7 mo 11 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housekeeping
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  Dudley S. Haynes
11. BIRTHPLACE OF FATHER:  KY
12. MAIDEN NAME OF MOTHER:  Emma L. Springgate
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  C. C. Carman
(Address)  Garfield, KY
15. Filed  Feb. 7, 1912
REGISTRAR:  James T. Mitcham
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Feb. 7, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Apr 28, 1912
That I last saw him/her alive on (date):  Feb. 7 1912
And that death occurred on the date stated above at (time AM/PM):  9:00 PM
THE CAUSE OF DEATH was as follows:  Consumption of lungs

(Duration)   Years:            Months:         10 Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. A. Sondbach
Date:  Feb. 8, 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
DATE OF BURIAL:  Feb. 8, 1912
20. UNDERTAKER:  R. O. Penick
ADDRESS:  Custer, KY