************************************************************************ 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.: Rockvale Inc Town: City: No. St. Ward: Registration District No.: 5320 Primary Registration District No: File No. 29829 Registered No: 2. FULL NAME: Clark, Stella PERSONAL AND STATICAL PARTICULARS 3. SEX: Female 4. COLOR OR RACE: White 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Single 6. DATE OF BIRTH: Nov. 18, 1907 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 5 yr 1 mo 6 da 8. OCCUPATION (a.) Trade, profession or particular kind of work: (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Breckinridge Co., KY 10. NAME OF FATHER: John Clark 11. BIRTHPLACE OF FATHER: Breckinridge Co., KY 12. MAIDEN NAME OF MOTHER: Lottie Thompson 13. BIRTHPLACE OF MOTHER: Ohio Co., KY 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) G. E. Clark (Address) Vanzant, KY 15. Filed Dec. 24, 1912 REGISTRAR: J. D. McDonoh MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: Dec. 24, 1912 17. I HEREBY CERTIFY, That I attended deceased from (date): Dec. 19, 1912 That I last saw him/her alive on (date): Dec. 24, 1912 And that death occurred on the date stated above at (time AM/PM): THE CAUSE OF DEATH was as follows: Acute laryngitis (Duration) Years: Months: Days: Contributory: (Duration) Years: Months: Days: Signed (M.D.): D. M. Matthews Date: Dec. 24, 1912 Address: Fordsville, 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: Clarks Graveyard DATE OF BURIAL: Dec. 25, 1912 20. UNDERTAKER: L. D. Orr ADDRESS: Jones, KY ************************************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm http://www.usgwarchives.net/ky/kyfiles.html ************************************************************************