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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge	
Vot. Pol.:  Custer
Inc Town:  Custer
City:  
No.  
St.  
Ward:  
Registration District No.:  5315
Primary Registration District No:  
File No.  9239
Registered No:  
2. FULL NAME:  Clark, Roxey
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  Dec. 16, 1892
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  19 yr 4 mo 3 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  At home
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., KY
10. NAME OF FATHER:  James R. Clark
11. BIRTHPLACE OF FATHER:  Breckinridge Co., KY
12. MAIDEN NAME OF MOTHER:  Sarah Morgan Thomas
13. BIRTHPLACE OF MOTHER:  Hardin Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Sarah M. Clark
(Address)  Custer, KY
15. Filed  Apr. 23, 1912
REGISTAR:  R. O. Penick
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Apr. 19, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Jan. 1911
That I last saw him/her alive on (date):  Apr 19, 1912
And that death occurred on the date stated above at (time AM/PM):  9 AM
THE CAUSE OF DEATH was as follows:  Tuberculosis of lungs

(Duration)   Years:            Months:  10         Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. W. Meador
Date:  Apr. 19, 1912
Address:  Custer, 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:  Lanham graveyard
DATE OF BURIAL:  Apr. 20, 1912
20. UNDERTAKER:  R. O. Penick
ADDRESS:  Custer, KY

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Copyright.  All rights reserved.
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