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1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  
Inc Town:  IRVINGTON, KY
City:  
No.  
St.  
Ward:  
Registration District No.:  5312
Primary Registration District No:  
File No.  67471
Registered No:  
2. FULL NAME:  CHAMBERLAIN, CHARLES L.
PERSONAL AND STATICAL PARTICULARS
3. SEX:  MALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6. DATE OF BIRTH:  MAY 24, 1851
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  63 YR 2 MO 2 DA
8. OCCUPATION (a.) Trade, profession or particular kind of work:  RETIRED ENGINEER
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  OHIO
10. NAME OF FATHER:  HIRAM CHAMBERLAIN
11. BIRTHPLACE OF FATHER:  VERMONT
12. MAIDEN NAME OF MOTHER:  LYDIA  DERVEAUX
13. BIRTHPLACE OF MOTHER:  OHIO
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  L. B. MOORMAN
(Address)  IRVINGTON, KY
15. Filed  AUG. 10, 1914
REGISTRAR:  MRS. SUE C. JOLLY
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  JULY 26, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  APRIL 1914
That I last saw him/her alive on (date):  JULY 25, 1914
And that death occurred on the date stated above at (time AM/PM):  3 PM
THE CAUSE OF DEATH was as follows:  CHRONIC INTESTINAL NEPHRITIS

(Duration)   Years:     2       Months:           Days:  
Contributory:  VALVULAR HEART TROUBLE

(Duration)   Years:            Months:       4     Days:  
Signed (M.D.):  L. B. MOORMAN
Date:  JULY 26, 1914
Address:  IRVINGTON, 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:  CHARDON, OHIO
DATE OF BURIAL:  
20. UNDERTAKER:  G. T. MARSHALL & SON
ADDRESS:  IRVINGTON, KY