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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.: ROCKVALE 
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5320
Primary Registration District No:  
File No.  28703
Registered No:  
2.	FULL NAME:  JOHNSON, PAUL ELMER
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  NO
6.	DATE OF BIRTH:  DEC 2, 1912
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  0 / 11 / 8
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  AT HOME
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  BRECKINRIDGE
10.	NAME OF FATHER:  BEN JOHNSON
11.	BIRTHPLACE OF FATHER:  GRAYSON COUNTY
12.	MAIDEN NAME OF MOTHER:  ETHEL MARLOW
13.	BIRTHPLACE OF MOTHER:  BRECKINRIDGE
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  J.J. CHANCELLOR
(Address)  VANZANDT
15.	Filed  NOV 10, 1913
REGISTAR:  J.D. McDONOUGH
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  NOV 10, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows:  HEART FAILURE
(Duration)   Years:            Months:            Days:    
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  NO DOCTOR
Date:  
Address:  
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:  CHANCELLOR GRAVEYARFD
DATE OF BURIAL:  NOV 11, 1913
20.	UNDERTAKER:  HANCOCK COUNTY
ADDRESS:  


ADDITIONAL COMMENTS/NOTES:




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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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