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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  HUDSON
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  5316
File No.  6377
Registered No:  1
2.	FULL NAME:  CHANEY, PALISTENE WEST
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  FEMALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  WIDOW
6.	DATE OF BIRTH:  DEC 15, 1860
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  52 / 3 / 10
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  HOUSEWIFE
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  CONSTANTINE, KY
10.	NAME OF FATHER:  GREEN G. WEST
11.	BIRTHPLACE OF FATHER:  WAYNE CO, KENTUCKY
12.	MAIDEN NAME OF MOTHER:  MARGRETT SUSBURY
13.	BIRTHPLACE OF MOTHER:  GARFIELD, KENTUCKY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  WILL CHANEY
(Address)  CONSTANTINE, KY
15.	Filed  AUG 25, 1913
REGISTAR:  J.H. CONNER
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  MAR 25, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  AUG 12, 1908 to MAR 24, 1913
That I last saw him/her alive on (date):  MAR 24, 1913
And that death occurred on the date stated above at (time AM/PM):  9 AM
THE CAUSE OF DEATH was as follows:  TUBERCULOSIS
(Duration)   Years:     4       Months:     7       Days:   12    
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  H.C. STONE
Date:  MAR 25, 1913
Address:  CONSTANTINE, 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:  COOK'S CEMETERY
DATE OF BURIAL:  MAR 26, 1913
20.	UNDERTAKER:  R.E. GIVENS
ADDRESS:  CONSTANTINE, KY


ADDITIONAL COMMENTS/NOTES:




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