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

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1.        PLACE OF DEATH

County:  BRECKINRIDGE

Vot. Pol.:  ROCKVALL

Inc Town:  

City:  

No.  

St.  

Ward:  

Registration District No.:  132

Primary Registration District No:  

File No.  22338

Registered No:  

2.        FULL NAME:  CLARK, GEORGE W.

PERSONAL AND STATICAL PARTICULARS

3.        SEX:  MALE

4.        COLOR OR RACE:  WHITE

5.        SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED

6.        DATE OF BIRTH:  DEC 12, 1868

7.        AGE  (yr. mo. da) (If less than 1 day, hours or min?):  42 / 7 / 4

8.        OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER

(b.)  General nature of industry business or establishment which employed:  

9.        BIRTHPLACE:  BRECKINRIDGE

10.     NAME OF FATHER:  WILLIAM E. CLARK

11.     BIRTHPLACE OF FATHER:  MEADE CO, KY

12.     MAIDEN NAME OF MOTHER:  ANGELINE ODELL

13.     BIRTHPLACE OF MOTHER:  IDNIANA

14.     THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)  W.C. CLARK

(Address)  VANZANT, KY

15.     Filed  JUL 17, 1911

REGISTAR:  E.L. ANDERSON

MEDICAL CERTIFICATE OF DEATH

16.     DATE OF DEATH:  JUL 16, 1911   [DELAYED]

17.     I HEREBY CERTIFY, That I attended deceased from (date):  JUN 21, 1911 to JUL 13, 1911

That I last saw him/her alive on (date):  JUL 13, 1911

And that death occurred on the date stated above at (time AM/PM):  11 AM

THE CAUSE OF DEATH was as follows:  DYSENTERY

 

(Duration)   Years:            Months:            Days:  

Contributory:  WATER

 

(Duration)   Years:            Months:            Days:  

Signed (M.D.):  C. DeWEESE

Date:  JUL 16, 1911

Address:  FORDSVILLE

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:  HOPEWELL BURYING GROUND

DATE OF BURIAL:  JUL 17, 1911

20.     UNDERTAKER:  W.C. CLARK, ACTING

ADDRESS:  VANZANT

 

TRANSCRIBER’S NOTE:  


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