1.       PLACE OF DEATH

County: Breckinridge KY

Vot. Pol.: Hardinsburg

Inc Town: Hardinsburg

City:

No.

St.

Ward 8

Registration District No.:

Primary Registration District No:

File No. 14257

Registered No: 34

2.       FULL NAME: Shelley Haynes

PERSONAL AND STATICAL PARTICULARS

3.       SEX: Female

4.       COLOR OR RACE: Black

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

6.       DATE OF BIRTH: June 24, 1896

7.       AGE  (yr. mo. da) (If less than 1 day, hours or min?): 15 yrs

8.       OCCUPATION (a.) Trade, profession or particular kind of work: House Keeper

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

9.       BIRTHPLACE: Hardinsburg Breckinridge Co KY

10.   NAME OF FATHER: George Haynes

11.   BIRTHPLACE OF FATHER: Hardinsburge Breckinridge Co KY

12.   MAIDEN NAME OF MOTHER: Chany Guthry

13.   BIRTHPLACE OF MOTHER: Hardinsburg Breckinridge Co KY

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

(Informant) Indive Haynes

(Address) Hardinsburg Breckinridge Co KY

15.   Filed Jne 24, 1911

REGISTAR: W B Lennon

MEDICAL CERTIFICATE OF DEATH

16.   DATE OF DEATH: June 24, 1911

17.   I HEREBY CERTIFY, That I attended deceased from (date): June 3, 1911 to June 22, 1911

That I last saw him/her alive on (date): June 22, 1911

And that death occurred on the date stated above at (time AM/PM): 10 AM

THE CAUSE OF DEATH was as follows: Disease of the liver Et, desease of nutrishion

 

(Duration)

Years:

Months: about 4

Days: 

Contributor: Cattorsh of Stomach and Bowels

(Duration)

Years:

Months:

Days: 4 

Signed (M.D.): James C. Sutton

Date: June 24, 1911

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  Colored Cemetery

DATE OF BURIAL: June 27, 1911

20.   UNDERTAKER: J T Hoben

ADDRESS: Hardinsburg, KY