1. PLACE OF DEATH
County: BRECKINRIDGE
Vot. Pol.: HUDSON
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
County: BRECKINRIDGE
Vot. Pol.: HUDSON
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
1. PLACE OF DEATH
County: BRECKINRIDGE
Vot. Pol.: HUDSON
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
County: BRECKINRIDGE
Vot. Pol.: HUDSON
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
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