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

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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.  14277

Registered No: 12 

2.        FULL NAME:  SILAS, DESIRE CHANEY

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  MALE

4.        COLOR OR RACE:  WHITE

5.        SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED

6.        DATE OF BIRTH:  NOV 14, 1876

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  34 / 69 / 26

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

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

9.        BIRTHPLACE:  INDIANA

10.     NAME OF FATHER:  ARCHIE B. CHANEY

11.     BIRTHPLACE OF FATHER:  KENTUCKY

12.     MAIDEN NAME OF MOTHER:  ELIZA A. PHILLIPS

13.     BIRTHPLACE OF MOTHER:  INDIANA

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

(Informant)  ARCHIE B. CHANEY

(Address)  COLES, ILLINOIS

15.     Filed  JUN 13, 1911

REGISTAR:  J.H. CONNER

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  JUN 9, 1911

17.     I HEREBY CERTIFY, That I attended deceased from (date):  MAY 18, 1911 to JUN 7, 1911

That I last saw him/her alive on (date):  JUN 7, 1911

And that death occurred on the date stated above at (time AM/PM):  11:15 PM

THE CAUSE OF DEATH was as follows:  CARDIAC DROPSEY

 

(Duration)   Years:      3      Months:            Days:  

Contributory:  LEUKEMIA

 

(Duration)   Years:            Months:    6        Days:  15

Signed (M.D.):  S.J.HALL

Date:  JUN 9, 1911

Address:  CONSTANTINE

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:  COYLES CHURCH

DATE OF BURIAL:  JUN 10, 1911

20.     UNDERTAKER:  RHODES & STORMS

ADDRESS:  McDANIEL, KY

 

TRANSCRIBER’S NOTE:  



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