Date:   04 March 1941
Cert:   07977 
Place of Death: County: Knott     City or Town: Boleyn
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky.      County: Knott
City or Town:  Boleyn
Full Name:  Jasper CHAFFINS
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Widowed
Husband or Wife of:  Mandy CHAFFINS
Age of husband or wife if alive:  deceased
Birth date of deceased:  1862
Age: 78 years
Birthplace:  Knott Co.
Occupation:  Farmer
Industry or business: (blank)
Father Name:  Nelson CHAFFINS
Father Birthplace:  Floyd
Mother Maiden Name:  Seattie SUTTON
Mother Birthplace:  Floyd Co.
Informant:  Zeer CHAFFINS, Mousie, Ky.
Burial Place:  Rock Fork
Date:  05 March 1941
Signature of funeral director: (blank)
Date received by local registrar:  06 March 1941
Registrar's Signature:  Macie Miller
Date of Death:  04 March 1941
I hereby certify that I attended deceased from (blank) to (blank), that I last saw him alive on (blank), and that death occurred on the date stated above at (blank)
Immediate cause of death:  Heart failure
Duration: (blank)
Due to: Dilation Heart
Major findings of operations: (blank)
Accident, suicide, or homicide: (blank)
Date of occurrence: (blank)
Where did injury occur: (blank)
While at work: (blank)
Means of injury: (blank)
Signature & Address: J. W. Duke, M.D., Hindman
Date signed:  06 March
Transcribed by Debbie Tamborski, 11 October 2010