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1.	PLACE OF DEATH
County:  BRECKINRIDGE
Vot. Pol.:  BALLTOWN
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5321
Primary Registration District No:  
File No.  300
Registered No:  4
2.	FULL NAME:  BATES, SAMUEL D.
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  WIDOWED
6.	DATE OF BIRTH:  OCT. 7, 1829
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  84 YR 3 MO 10 DA
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  KY
10.	NAME OF FATHER: JOHN D. BATES  
11.	BIRTHPLACE OF FATHER:  KY
12.	MAIDEN NAME OF MOTHER:  SARAH DUNCAN
13.	BIRTHPLACE OF MOTHER:  KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  T. M. BATES
(Address)  FREE, KY
15.	Filed  JAN 18, 1913
REGISTAR:  FRED FRANK
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  JAN 17, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  
THE CAUSE OF DEATH was as follows: INFIRMITIES INCIDENT TO OLD AGE  

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  
Date:  
Address:  
18.	LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents)
At place of death (yr, mo, da.):  
In the State (yr, mo, da):  
Where was disease contracted,  if not at place of death?  
Former or usual residence:  
19.	PLACE OF BURIAL OR REMOVAL:  PISGAH
DATE OF BURIAL:  JAN 18, 1913
20.	UNDERTAKER:  M. HAMMAN & SON
ADDRESS:  CLOVERPORT, KY


ADDITIONAL COMMENTS/NOTES:




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Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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