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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg, Ky
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5302
File No.  5831
Registered No:  
2. FULL NAME:  John Payne
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  [blank]
6. DATE OF BIRTH:  [unreadable] 1861
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  53 years
8. OCCUPATION (a.) Trade, profession or particular kind of work:  [blank]
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  [blank]
10. NAME OF FATHER:  [blank]
11. BIRTHPLACE OF FATHER:  [blank]
12. MAIDEN NAME OF MOTHER:  [blank]
13. BIRTHPLACE OF MOTHER:  [blank]
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  [blank]
(Address)  [blank]
15. Filed  march 2, 1914
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Feb. 19, 1914 {stamped with DELAY]
17. I HEREBY CERTIFY, That I attended deceased from (date):  [blank]
That I last saw him/her alive on (date):  [blank]
And that death occurred on the date stated above at (time AM/PM):  [blank]
THE CAUSE OF DEATH was as follows:  Appolexy
 
(Duration)   Years:            Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. S. Shoemaker
Date:  
Address:  Kingswood, 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:  [blank]
DATE OF BURIAL:  Feb. 20, 1914
20. UNDERTAKER:  Robt. Weatherford
ADDRESS:  Harned, Ky
 

ADDITIONAL COMMENTS/NOTES:
Breckinridge County Cemeteries, Volume 1, page 351 shows the following information:
John A Payne, born 27 May 1861, died 19 Feb 1914, husband of Emma Carman is buried in Scott Payne, Harned Cemetery #1 - Harned, Kentucky
 
 

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