1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hudson
Registration District No.:
Primary Registration District No: 5316
File No. 11907
Registered No: 9
1. FULL NAME: John Calaway Chaney
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Feb 22, 1857
6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 55yrs3mos5ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.) General nature of industry business or establishment which employed:
8. BIRTHPLACE: Pulaska (Pulaski) Co, Ky
9. NAME OF FATHER: Hiram Chaney
10. BIRTHPLACE OF FATHER: not known
11. MAIDEN NAME OF MOTHER: Sarah Esam
12. BIRTHPLACE OF MOTHER: not known
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Palestine Chaney
(Address) Constantine, Ky
14. Filed 5/30/1912
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: May 28, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): 2 or 3 years
That I last saw him/her alive on (date): May 28, 1912
And that death occurred on the date stated above at (time AM/PM): 9PM
THE CAUSE OF DEATH was as follows:
Diabetes Mellitus
(Duration)
Years: 4
Months:
Days:
Contributory: Kidneys
Signed (M.D.): H.C. Stone
Date: May 28, 1912
Address: Constantine, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Cook Cemetery
DATE OF BURIAL: May 30, 1912
19. UNDERTAKER: Pete Bennett
ADDRESS: Hudson, Ky
County: Breckinridge
Vot. Pol.: Hudson
Registration District No.:
Primary Registration District No: 5316
File No. 11907
Registered No: 9
1. FULL NAME: John Calaway Chaney
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Feb 22, 1857
6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 55yrs3mos5ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.) General nature of industry business or establishment which employed:
8. BIRTHPLACE: Pulaska (Pulaski) Co, Ky
9. NAME OF FATHER: Hiram Chaney
10. BIRTHPLACE OF FATHER: not known
11. MAIDEN NAME OF MOTHER: Sarah Esam
12. BIRTHPLACE OF MOTHER: not known
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Palestine Chaney
(Address) Constantine, Ky
14. Filed 5/30/1912
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: May 28, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): 2 or 3 years
That I last saw him/her alive on (date): May 28, 1912
And that death occurred on the date stated above at (time AM/PM): 9PM
THE CAUSE OF DEATH was as follows:
Diabetes Mellitus
(Duration)
Years: 4
Months:
Days:
Contributory: Kidneys
Signed (M.D.): H.C. Stone
Date: May 28, 1912
Address: Constantine, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Cook Cemetery
DATE OF BURIAL: May 30, 1912
19. UNDERTAKER: Pete Bennett
ADDRESS: Hudson, Ky
1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: Hudson
Registration District No.:
Primary Registration District No: 5316
File No. 11907
Registered No: 9
1. FULL NAME: John Calaway Chaney
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Feb 22, 1857
6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 55yrs3mos5ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.) General nature of industry business or establishment which employed:
8. BIRTHPLACE: Pulaska (Pulaski) Co, Ky
9. NAME OF FATHER: Hiram Chaney
10. BIRTHPLACE OF FATHER: not known
11. MAIDEN NAME OF MOTHER: Sarah Esam
12. BIRTHPLACE OF MOTHER: not known
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Palestine Chaney
(Address) Constantine, Ky
14. Filed 5/30/1912
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: May 28, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): 2 or 3 years
That I last saw him/her alive on (date): May 28, 1912
And that death occurred on the date stated above at (time AM/PM): 9PM
THE CAUSE OF DEATH was as follows:
Diabetes Mellitus
(Duration)
Years: 4
Months:
Days:
Contributory: Kidneys
Signed (M.D.): H.C. Stone
Date: May 28, 1912
Address: Constantine, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Cook Cemetery
DATE OF BURIAL: May 30, 1912
19. UNDERTAKER: Pete Bennett
ADDRESS: Hudson, Ky
County: Breckinridge
Vot. Pol.: Hudson
Registration District No.:
Primary Registration District No: 5316
File No. 11907
Registered No: 9
1. FULL NAME: John Calaway Chaney
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: Feb 22, 1857
6. AGE (yr. mo. da) (If less than 1 day, hours or min?): 55yrs3mos5ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: farmer
(b.) General nature of industry business or establishment which employed:
8. BIRTHPLACE: Pulaska (Pulaski) Co, Ky
9. NAME OF FATHER: Hiram Chaney
10. BIRTHPLACE OF FATHER: not known
11. MAIDEN NAME OF MOTHER: Sarah Esam
12. BIRTHPLACE OF MOTHER: not known
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Palestine Chaney
(Address) Constantine, Ky
14. Filed 5/30/1912
REGISTAR: JH Comer
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: May 28, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): 2 or 3 years
That I last saw him/her alive on (date): May 28, 1912
And that death occurred on the date stated above at (time AM/PM): 9PM
THE CAUSE OF DEATH was as follows:
Diabetes Mellitus
(Duration)
Years: 4
Months:
Days:
Contributory: Kidneys
Signed (M.D.): H.C. Stone
Date: May 28, 1912
Address: Constantine, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Cook Cemetery
DATE OF BURIAL: May 30, 1912
19. UNDERTAKER: Pete Bennett
ADDRESS: Hudson, Ky
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