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DEATH
CERTIFICATE
DAVID STACY
Date 16 December 1927
Cert: 28440
Place of Death: Golden Rule Hospital,
Paintsville, Johnson Co., Ky.
Full Name: David STACY
Residence: (blank)
Length of Residence in city where death occurred:
(blank)
Sex, Color or Race, Marital Status: Male, White, Married
Husband or Wife of: Luelzia STACY
Date of Birth: 10 June 1899
Age: 28 years, 06 months, 06 days
Occupation: Farmer
Birthplace: Knot Co., Ky.
Father Name: Sparrel STACY
Birthplace Father: Breathitt Co., Ky.
Mother Maiden Name: America CLEMONS
Birthplace Mother: Ky.
Informant/Address: Jas. B. STACY, Decoy, Ky.
Filed: 09 January 1928
Registrar: Mrs. O. B. Hall
Death of Date: 16 December 1927
I hereby certify that I attended deceased from 15 December
1927 to 16 December 1927, that I last saw him alive on 16
December 1927, and that death occurred on the date stated
above at 5 a.m.
Cause of Death: A revolver shot through pelvis & abdomen
(illegible) by another person through anger
Duration: (blank)
Contributory: General peritonitis & shock
Duration: 1 1/2 days
Where was disease contracted if not at place of death?:
(blank)
Did an operation precede death: No Date: (blank)
Was there an autopsy: No
What test confirmed diagnosis: Bullet wound
Signed/Address: J. A. Wells, M.D., Paintsville, Ky.
Place of Burial or Removal: Carver, Ky.
Date of Burial: 18 December 1927
Undertaker/Address: F. J. Conley, Paintsville, Ky.
Transcribed by Debbie Tamborski, 23 March 2010 |
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