Death Certificate of Powhatan H. Clarke - August 30, 1920
Transcript
12-30-24-2000 (21-3516) STATE OF NEW YORK City and County of Albany} ss: I, MATTHIAS NICOLL, JR., Commissioner of Health of the State of New York, do hereby certify that the annexed is a copy of a certificate of the death of POWHATAN H. CLARKE at Village of Saranac Lake, Franklin Co. N.Y., on August 30, 1920 state number 50924 required by law to be filed in the office of the State Department of Health; that the original thereof is on file in that office; that I have compared said copy with such original, and that it is a correct transcript therefrom and of the whole thereof. WITTNESS my hand and the seal of the State Department of Health and the City of Albany this twentieth day of April, 1925. Matthias Nicoll Jr. Commissioner of Health.
Transcript
(Dist. No1623) To be inserted by Registrar New York State Department of Health DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH 50924 STATE OF NEW YORK Registered No. 167 1 Place of Death County Franklin Town or Village or City Saranac Lake 2 FULL NAME Powhatan H. Clarke (18a) Residence No. 84 Park Ave Length of Residence in city or town where death occurred[yrs.] 3w PERSONAL AND STATISTICAL PARTICULARS 3 SEX Male 4 COLOR OR RACE White 5 SINGLE, MARRIED, WIDOWED OR DIVORCED (Write the word) Single 6 DATE OF BIRTH April 5th 1893 7 AGE Years 27 Months 4 Days 25 8 OCCUPATION Lawyer 9 BIRTHPLACE(City or Town) Fort Custer (State or Country) Montana [10 NAME OF FATHER] Powhatan Clarke 11 BIRTHPLACE OF FATHER (City or Town) Rapids Parish (State or Country)[Georgia] 12 MAIDEN NAME OF MOTHER Elsie Clements 13 BIRTHPLACE OF MOTHER (City or Town) St Louis (State or Country) [Missouri] 14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) [ms illegible: 1 wd] Clemetn (Clemens) (Address) St Louis [Missouri] 15 Filed 8/31, 1920 GH Parsons REGISTRAR MEDICAL CERTIFICATE OF DEATH 16 DATE OF DEATH [August] 30, 1920 17 I HEREBY CERTIFY, That I attended deceased from [August] 13th, 1920, to [August] 30th, 1920, that I saw him alive on Aug 30th, 1920, and that death occurred on the date stated above, at 7.25 AM The CAUSE OF DEATH* was as follows: Pulmonary Tuberculosis (Duration) [years] 1
Transcript
Revised United States Standard Certificate of Death [stamp] FILED VS [September] 7 1920 [New York] STATE DEPT. OF HEALTH
Details
| Title | Death Certificate of Powhatan H. Clarke - August 30, 1920 |
| Creator | Unknown |
| Source | Unknown. Death Certificate of Powhatan H. Clarke. 30 August 1920. Clarke, Powhatan Papers. A0293. Missouri History Museum, Saint Louis, Missouri. |
| Description | Death certificate of Powhatan H. Clarke. He died August 30, 1920 after contracting tuberculosis in St. Louis, Missouri. He was buried at Calvary Cemetery in St. Louis. Clarke served with the 21st Aero Squadron and Labor Bureau A.E.F. during Word War I. |
| Subject LCSH | Tuberculosis |
| Subject Local | World War I; WWI |
| Site Accession Number | A0293 |
| Contributing Institution | Missouri History Museum |
| Copy Request | Transmission or reproduction of items on these pages beyond those allowed by fair use requires the written permission of the Missouri History Museum: 314-746-4510 |
| Rights | The text and images contained in this collection are intended for research and educational use only. Duplication of any of these images for commercial use without express written consent is expressly prohibited. Contact the Missouri History Museum's Permissions Office at 314-746-4511 to obtain written consent. |
| Date Original | August 30, 1920 |
| Language | English |