1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.: 5307
Inc Town: Cloverport, Ky
City:
No.
St.
Ward: 3rd
Registration District No.: 131
Primary Registration District No: 2065
File No. 16543
Registered No: 68
1. FULL NAME: Eugene H Kingsbury
PERSONAL AND STATICAL PARTICULARS
2. SEX: male
3. COLOR OR RACE: white
4. SINGLE, MARRIED, WIDOWED, OR DIVORCED: married
5. DATE OF BIRTH: March 13, 1851
6. AGE  (yr. mo. da) (If less than 1 day, hours or min?): 62yrs3mos28ds
7. OCCUPATION (a.) Trade, profession or particular kind of work: Carpenter
(b.)  General nature of industry business or establishment which employed: Contracting & building
8. BIRTHPLACE: New York
9. NAME OF FATHER: Wm Kingsbury
10. BIRTHPLACE OF FATHER: Connecticut
11. MAIDEN NAME OF MOTHER: Mary Evans
12. BIRTHPLACE OF MOTHER: South Wales
13. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Fannie D (?) Lousey
(Address) Cloverpor, Ky
14. Filed July 11, 1912
REGISTAR: JC Nolte
MEDICAL CERTIFICATE OF DEATH
15. DATE OF DEATH: July 10, 1912
16. I HEREBY CERTIFY, That I attended deceased from (date): Juky 10, 1912 to July 10, 1912 
That I last saw him/her alive on (date): July 10, 1912
And that death occurred on the date stated above at (time AM/PM): 10:30 PM
THE CAUSE OF DEATH was as follows:
Acute arsenical poisoning, suicidal
(Duration)
Years:
Months:
Days: ˝
Contributory: Alcoholism………30 years
Signed (M.D.): A.A. Simons
Date: July 10, 1912
Address: Cloverport, Ky
17. 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:
18. PLACE OF BURIAL OR REMOVAL: Cloverport, Ky
DATE OF BURIAL: July 12, 1912
19. UNDERTAKER: M Hamman  Sons
ADDRESS: Cloverport, Ky