Loudon County Genealogy & History Website Loudon County Death Certificates
 

CERTIFICATE OF DEATH
STATE OF TENNESSEE
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF VITAL STATISTICS

 

William Jacob Clark
Reg. Number:  621092; Reg. District: Loudon
Certificate Number: 621092

Name: William Jacob Clark
Residence: Lenoir City R-4 E. Lee Hwy
Sex: Male
Race: W
Date of Birth: 20 Dec 1876
Place of Birth: Roane TN
Date of Death: 13 Nov 1961
Place of Death: Residence
Age: 84
Marital Status: Married
Spouse, if living: Rebecca D Varner Clark
Age of Spouse, if living:
If Veteran, Name of War:
Social Security Number:
Occupation: Farmer
Industry or Business: (left blank)
Father's Full Name: John Clark
Father's Birthplace: Canada
Mother's Full Maiden Name: Margarette Shubert Clark
Mother's Birthplace: Roane TN
Cause of Death:
  • Due to: (left blank)
  • Other conditions: (left blank)
  • Operation?: (left blank)
  • Autopsy?: (left blank)
If death was due to external causes, fill in the following:
  • Accident, Suicide, or Homicide: (left blank)
  • Date of Occurrence: 19
  • Where did the injury occur: (left blank)
  • Did injury occur in or about home, on farm, in industrial place, in public place?: (left blank)
  • While at work: (left blank)
  • Means of Injury: (left blank)
Informant:
Informant Address:
Burial, Removal, or Cremation: Bur
Date: 15 Nov 1961
Undertaker: Dr. Sam Harrison
Address:
By:
Date Filed: 19
Registrar:
Signature:
Address:

Submitter's Name: Steve Clark
Submitter's Email: greyfix@charter.net
Relationship to the Deceased: GGgrandson

Comments:





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