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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  BIG SPRING
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.: 5314 
Primary Registration District No: 15 
File No.  6373
Registered No: 44 
2.	FULL NAME: JAMES MADISON HENDERSON 
PERSONAL AND STATICAL PARTICULARS
3.	SEX: M 
4.	COLOR OR RACE: W 
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED: INFANT 
6.	DATE OF BIRTH: MARCH 5, 1913 
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?): 12DS 
8.	OCCUPATION (a.) Trade, profession or particular kind of work: INFANT  
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE CO, KY
10.	NAME OF FATHER: JESSE HENDERSON 
11.	BIRTHPLACE OF FATHER: KENTUCKY 
12.	MAIDEN NAME OF MOTHER:  IDA SIMMONS
13.	BIRTHPLACE OF MOTHER:   BRECKINRIDGE CO, KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) JUNE WOODS 
(Address) CUSTER, KY 
15.	Filed MAR 17, 1913 
REGISTAR: (JAMES T. MITCHAM) 
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH: MARCH 17, 1913 
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him alive on (date): MCH 5, 1913 
And that death occurred on the date stated above at (time AM/PM): 11 AM 
THE CAUSE OF DEATH was as follows:  
MENINGITIS
(Duration)   Years:            Months:            Days:  1
Contributory:  CONVULSIONS

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J.W. MEADOR
Date: MAR 17, 1913 
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:  SANAIRES B. GR.
DATE OF BURIAL: MARCH 18, 1913 
20.	UNDERTAKER:  JUNE WOODS
ADDRESS:  CUSTER, KY


ADDITIONAL COMMENTS/NOTES:




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