Leroy Payton Death Certificate
Indiana State Board of Health
Certificate of Death
Registered No. 21179
Place of Death:
County of Morgan
Township of Ray
Village of [blank]
or
City of [blank] (No. [blank], [blank] St.; [blank] Ward]
FULL NAME: Leroy Payton
PERSONAL AND STATISTICAL PARTICULARS
SEX: Male
COLOR: White
DATE OF BIRTH: June 24, 1832
AGE: 86 years, 11 months, 17 days
SINGLE...: Widowed
NAME OF HUSBAND OR WIFE: [blank]
BIRTHPLACE OF DECEASED: Indiana
NAME OF FATHER: Wiley Payton
BIRTHPLACE OF FATHER: [blank]
MAIDEN NAME OF MOTHER: Lucy Brown
BIRTHPLACE OF MOTHER: [blank]
OCCUPATION OF DECEASED: Retired
The above stated personal particulars are true to the best of my knowledge and belief:
(Informant) Mrs. Wm. Gearen
(Address) Paragon, Ind
R.F.D. #1
Burial Permit Issued by: H. H. Dutton, Paragon, Ind.
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH: June 10, 1918
I HEREBY CERTIFY, That I attended deceased from April 3, 1918 to June 9 1918 that I last saw him alive on June 9, 1918 and that death occurred, on the date stated above, at 3 A.M. The CAUSE OF DEATH was as follows:
Senility
Contributory: Chronic Gastritis
Duration: 5 yrs. [blank] mos. [blank] ds.
(Signed) E. L. Eggers, M.D.
June 10, 1918 (Address) Paragon, Ind
PLACE OF BURIAL OR REMOVAL: Baker Twp. Union Cemetery
DATE OF BURIAL: June 11, 1918
UNDERTAKER: Paul Begaman
NO. OF LICENSE: 925
ADDRESS: Paragon, Ind.
WAS THE BODY EMBALMED? Yes
Transcription by John C. Hepner, 1998