Transcribed by Darrell Warner BOURBON COUNTY, KENTUCKY DEATH CERTIFICATE OF ELIZA (WARNER) CLARK 1. Place of death County: Bourbon Inc. town: North Middleton Registration district number: 93 Primary registration districr number: 4178 File number: 27682 Registered number: 80 2. Full name: Eliza Clark 3. Sex: female 4. Color or race: white 5. Single, married, widowed or divorced: widowed 5a. If married, widowed or divorced name of husband: John A. Clark 6. Date of birth: 1960 7. Age: 72 8, 9, 10 and 11. Occupation: housekeeper 12: Birthplace: Kentucky 13. Name of father: Jacob Warner 14. Birthplace of father: Kentucky 15. Maiden name of mother: Elizabeth Shultz 16. Birthplace of mother: Kentucky 17. Informant: Mattie Clark RR2 Paris, Kentucky 18. Burial: Old Fields Cemetery December 24, 1932 19. Undertaker: Shrout, Piper and Shrout, Owingsville, Kentucky 20. Filed: 1-12-1933 21. Date of death: December 22, 1932 22. Cause of death: myocarditis 23. Was death accident, suicide of homicide: no 24. Signed: G. A. Cook