Date:   21 July 1941
Cert:   22638 
Place of Death: County: Knott     City or Town: Rural (Anco)
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky.      County: Perry
City or Town:  Rural
Full Name:  Chas. SMITH
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Male, White, Married
Husband or Wife of:  Helen
Age of husband or wife if alive: 15 years
Birth date of deceased:  26 November 1919
Age: 21 years, 07 months, 24 days
Birthplace:  Perry County
Occupation:  Coal Miner
Industry or business: (blank)
Father Name:  Jeff SMITH
Father Birthplace:  Tenn.
Mother Maiden Name:  Polly BAKER
Mother Birthplace:  Perry County
Informant:  Evert SMITH, Blue Diamond
Burial Place:  Englewood - Diablock
Date:  22 July 1941
Signature of funeral director: Engle Und. & Hdwe. Co., Main St., Hazard, Ky.
Date received by local registrar: 17 September 1941
Registrar's Signature:  Phena Slone
Date of Death:  21 July 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:  Fractured skull
Duration: (blank)
Due to: (blank)
Major findings of operations: (blank)
Accident, suicide, or homicide: accident
Date of occurrence: (blank)
Where did injury occur: Coal Mine (Slate fall)
While at work: yes
Means of injury: Slate fall
Signature & Address: Chris S. Jackson, M.D., Hazard, Ky.
Date signed:  19 August 1941
Transcribed by Debbie Tamborski, 15 October 2010