N. B. - WRITE PLAINLY WITH UNFADING INK - THIS IS A PERMANENT RECORD.
Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS
should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of
OCCUPATION is very important. See instructions on back of certificate.

0 3 1 0 0 6 3 2
1 PLACE OF DEATH
County Davis
Precinct
Village
or
City Farmington
No.
State Board of Health File No. 23
462
STATE OF UTAH - DEATH CERTIFICATE
Eugene Henry Clark
St., Ward
[If death occurred in a
hospital or institution
give its NAME instead
of street and number.]

2 FULL NAME Eugene Henry Clark
(a) Residence. No. Farmington Utah
(USUAL PLACE OF ABODE)
(IF NON-RESIDENT GIVE CITY OR TOWN AND STATE)
Length of residence in city or town where death occurred 50 yrs. mos. ds. How long in U. S., if of foreign birth? yrs. mos. ds.

PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED,
OR DIVORCED (Write the word)
Married
5a If Married, Widowed, or Divorced
HUSBAND OF
(or) WIFE OF
Sadie Sessions
6 DATE OF BIRTH
Mar 20, 1873
(Month) (Day) (Year)
7 AGE
58 yrs. 0 mos. 29 ds.
If LESS than
1 day, hrs.
or min.?
8 OCCUPATION OF DECEASED
(a) Trade, profession or
particular kind of work
Farmer
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of Employer
Self
9 BIRTHPLACE (City or town)
Utah
(State or Country)
PARENTS
10 NAME OF
FATHER
Ezra T Clark
11 BIRTHPLACE
OF FATHER
(State or Country)
Illinois
12 MAIDEN NAME
OF MOTHER
Susan Leggett
13 BIRTHPLACE
OF MOTHER
(State or Country)
England
14
Informant A L Clark
Address Farmington Utah
15
Filed April 22 1931 J. H. Robinson
Registrar

MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
April 19, 1931
(Month) (Day) (Year)
17 I HEREBY CERTIFY, That I attended deceased from
March, 1931, to April 19, 1931,
that I last saw him alive on April 19, 1931,
and that death occurred, on the date stated above, at 4 P.m.
The CAUSE OF DEATH* was as follows:
Cerebral Apoplexy
1st Stroke1 yr. ago
2nd Stroke April 11
(Duration) yrs. mos. 8 ds.
Contributory First Stroke & Pneumonia
(Secondary)
Hyperstatic
(Duration) yrs. mos. 2 ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? no Date of
Was there an autopsy?
What test confirmed diagnosis? Clinical Picture
(Signed) E. W. O. Buchanan, M. D.
4/21/, 1931 (Address) Farmington
Utah
*State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT
CAUSES state (1) MEANS AND NATURE OF INJURY; and (2) whether
ACCIDENTAL, SUICIDAL OR HOMICIDAL. (See reverse side for ad-
ditional space.)

Registered Number
21 3
No. of Burial or Removal Permit
22 3
19 PLACE OF BURIAL, CREMATION OR
REMOVAL
Farmington Cem
DATE OF BURIAL
April 22, 1931
20 UNDERTAKER
Geo W Holbrook
ADDRESS
Bountiful,
Utah

READ CAREFULLY INSTRUCTIONS ON BACK OF CERTIFICATE