************************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm
http://www.usgwarchives.net/ky/kyfiles.html
************************************************

File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
http://www.usgwarchives.net

************************************************************************

1. PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  GLEN DEAN, KY
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5319
Primary Registration District No:  19
File No.  17485
Registered No:  
2. FULL NAME:  CLARK, DAVID
PERSONAL AND STATICAL PARTICULARS
3. SEX:  MALE
4. COLOR OR RACE:  WHITE
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  SINGLE
6. DATE OF BIRTH:  JAN. 15, 1878
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  36 YR 6 MO 2 DA
8. OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  ADOLPHUS CLARK
11. BIRTHPLACE OF FATHER:  VA
12. MAIDEN NAME OF MOTHER:  ALLICE FRANKS
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  MRS. REBECCA CLARK
(Address)  GLEN DEAN, KY
15. Filed  JULY 17, 1914
REGISTRAR:  MRS. MOLLY DEMPSTER
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  JULY 17, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  JULY 12, 1914
And that death occurred on the date stated above at (time AM/PM):  1 PM
THE CAUSE OF DEATH was as follows:  SUICIDE BY FIREARMS

(Duration)   Years:            Months:           Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  P. E. DEMPSTER
Date:  JULY 17, 1914
Address:  GLEN DEAN, 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:  GLEN DEAN CEMETERY
DATE OF BURIAL:  JULY 18, 1914
20. UNDERTAKER:  H. WILSON & CO.
ADDRESS:  GLEN DEAN, KY