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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Webster
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5311
Primary Registration District No:  
File No.  14024
Registered No:  
2. FULL NAME:  Comslim McFarlin
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  Negro
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  married
6. DATE OF BIRTH:  unknown, 1861
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  51
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Labor
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  unknown
11. BIRTHPLACE OF FATHER:  unknown
12. MAIDEN NAME OF MOTHER:  unknown
13. BIRTHPLACE OF MOTHER:  unknown
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Ella McFarlin
(Address)  Webster, KY
15. Filed  4/9, 1912
REGISTAR:  H. Drane
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  4-9, 1912 [DELAY stamped near the date]
17. I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  4-8, 1912
THE CAUSE OF DEATH was as follows:  Stomach [unreadable] on ZH & SLRR accidental
(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  T. J. Hendrick
Date:  4-9, 1912
Address:  Webster
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:  [blank]
DATE OF BURIAL:  4-14, 1912
20. UNDERTAKER:  G. T. Marshall
ADDRESS:  Irvington


ADDITIONAL COMMENTS/NOTES:




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