************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************

File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

************************************************************************
1.        PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  HUDSON

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  5316

Primary Registration District No:  

File No.  27668

Registered No: 17 

2.        FULL NAME:  CHANEY, EARSA MAY

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  FEMALE

4.        COLOR OR RACE:  WHITE

5.        SINGLE, MARRIED, WIDOWED, OR DIVORCED:  

6.        DATE OF BIRTH:  MAR 8, 1906

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  5 / 8 / 2

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

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

9.        BIRTHPLACE:  MOULTRIE CO, ILLINOIS

10.     NAME OF FATHER:  S. DENVER  CHANEY

11.     BIRTHPLACE OF FATHER:  BRECKINRIDGE

12.     MAIDEN NAME OF MOTHER:  SARAH N. PULLAM

13.     BIRTHPLACE OF MOTHER:  BRECKINRIDGE

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

(Informant)  J.R. BASHAM

(Address)  EVELEIGH, KY   [GRAYSON COUNTY]

15.     Filed  NOV 11, 1911

REGISTAR:  J.H. CONNER

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  NOV 10, 1911

17.     I HEREBY CERTIFY, That I attended deceased from (date):  NOV 4, 1911 to NOV 10, 1911

That I last saw him/her alive on (date):  NOV 4, 1911

And that death occurred on the date stated above at (time AM/PM):  5 AM

THE CAUSE OF DEATH was as follows:  FOLLICULAR TONSILITIS

 

(Duration)   Years:            Months:            Days:  15

Contributory:  

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  J.G. HALE

Date:  NOV 11, 1911

Address:  HARDIN SPRINGS

18.     LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)

At place of death (yr, mo, da.):  

In the State (yr, mo, da):  1 YR

Where was disease contracted,  if not at place of death?  

Former or usual residence:  ILLINOIS

19.     PLACE OF BURIAL OR REMOVAL:  COYLE’S CEMETERY

DATE OF BURIAL:  NOV 11, 191

20.     UNDERTAKER:  E.A. STONE

ADDRESS:  HARDIN SPRINGS

 

TRANSCRIBER’S NOTE:  

************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************