Leroy Payton Death Certificate

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

 

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