State of Tennessee
State Board of Health
Bureau of Vital Statistics
Certificate of Death
 

1. Place of death -- County: Sevier, Civil Dist.: 8, Registration District: 47908, File number: 229, Village: Kodak, Tenn.; Primary Registration District No.: 8  , Registered no.: 13.
2. Full name -- Harley Bryan
3. Sex -- Male
4. Color or race -- w
5. Single, married, widowed, or divorced -- married
6. Date of birth -- Month 2, Day 12, 1876
7. Age -- 39 yrs, 10 mos., 3 ds.
8. Occupation a) Trade, profession, or particular kinds of work .... Farmer;  b) General nature of business, or establishment in which employed.... Farm work
9. Birthplace -- Tenn
10. Name of father -- William Bryan
11. Birthplace of father -- Tenn
12. Maiden name of mother -- Malissa Underwood
13. Birthplace of mother -- Tenn
14. The above is true to the best of my knowledge (Informant) signed Mrs. Harley Bryan, Kodak, Tenn
15. Filed 1/16, 1916, G.C. Johnson
16. Date of death -- month 12 day 15, 1915
17. I hereby certify that I attended from month 12 day 12 1915 to month 12 day 15 1915 and that I last saw him alive on month 12 day 15 1915 and that death occurred on the date stated above at 10 A.M.  The cause of death was as follows:  Autointoxication  Signed F.R. French M.D., (Address) Dandridge, Tenn
18. Length of residence --
19. Place of burial or removal -- Bryan grave yard;  Date of burial -- 12/16, 1915
20. Undertaker -- Homer Atchley;  Address -- Sevierville