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- 1. PLACE OF DEATH
County Giles Registration District No. 284 File No.
Civil Dist. No. 17 Primary Registration District No. 17 Registered No. 2
Village or City
Full Name Benjamin Thomas Clark
Sex Male
Color or Race White
Singl e, Married, Widowed or Divorced Married
Date of Birth Sept 5, 1873
Age 41 y rs. 5 mos. 18 das.
Occupation Farmer
Birthplace Diana Giles Co
Name of Fa ther A Porter Clark
Birthplace of Father Giles Co
Maiden Name of Mother Fra nces
Birthplace of Mother
The Above Is True To The Best Of My Knowledge (In formant) Jackson Clark
Address R #1 Brick Church
Filed Feb 24, 1914; L. E. Wheat, Registrar
Date of Death Feb. 23, 1914
I HEREBY CERTIFY, That I atten ded deceased from Feb. 5, 1914 to Feb. 23,
1914 , that I last saw him alive o n Feb. 23, 1914 and that death
occurred, on the date state above, at 5 p.m.
THE CAUSE OF DEATH was as follows:
Appendicial abscess
Duration
Contributo ry
Signed Luther E. Wheat (Address) Brick Church
Length of Residence (Left B lank)
Place of Burial or Removal Mt. Pleasant Date of Burial Feb. 24, 1914
Undertaker Hindman, Oliver & Braly Address Pulaski
www.rootsweb.com/~tngiles/ death/dc1.htm
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