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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.:  HARDINSBURG

Inc Town:  

City:  

No.  

St.  

Ward:  4th

Registration District No.:  130

Primary Registration District No:  5304

File No.  5627

Registered No:  15

2.        FULL NAME:  CHAPIN, ELIZABETH BURCH

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  FEMALE

4.        COLOR OR RACE:  WHITE

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

6.        DATE OF BIRTH:  MAR 8, 1848

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  62 / 0 / 2

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

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

9.        BIRTHPLACE:  NOT KNOWN

10.     NAME OF FATHER:  HENLEY [?] BURCH

11.     BIRTHPLACE OF FATHER:  MARYLAND

12.     MAIDEN NAME OF MOTHER:  NANCY MATHEW

13.     BIRTHPLACE OF MOTHER:  KENTUCKY

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

(Informant)  ALLIE PATE

(Address)  HARDINSBURG

15.     Filed  MAR 11, 1911

REGISTAR:  W.B. LENNON

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  MAR 10, 1911

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

That I last saw him/her alive on (date):  MAR 10, 1911

And that death occurred on the date stated above at (time AM/PM):  10 P.M.

THE CAUSE OF DEATH was as follows:  ORGANIC HEART DISEASE

 

(Duration)   Years:      3      Months:            Days:  

Contributory:  

 

(Duration)   Years:       3     Months:            Days:  

Signed (M.D.):  A.M. KINCHELOR

Date:  MAR 11, 191

Address:  HARDINSBURG

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:  CLOVERPORT CEM

DATE OF BURIAL:  MAR 11, 1911

20.     UNDERTAKER:  B.F. BEARD & CO

ADDRESS:  HARDINSBURG

 

TRANSCRIBER’S NOTE: 

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