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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge	
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  130
Primary Registration District No:  5302
File No.  25004
Registered No:  61
2. FULL NAME:  James Broomfield Pate
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  Nov. 6, 1830
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  80 yrs.  11 mos.  7 ds.
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Miller
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Virginia
10. NAME OF FATHER:  John Pate
11. BIRTHPLACE OF FATHER:  Virginia
12. MAIDEN NAME OF MOTHER:  Eliza Ball
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  R. S. Pate
(Address)  Harned, Ky.
15. Filed  Oct 14, 1911
REGISTAR:  W. B. Lennon
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Oct. 13, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  Aug 6, 1911 to Oct. 13, 1911
That I last saw him/her alive on (date):  Oct. 13, 1911
And that death occurred on the date stated above at (time AM/PM):  4:30 a.m.
THE CAUSE OF DEATH was as follows:  Paralysis

(Duration)   Years:            Months:   2         Days:  7
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  W. H. Lucas, M.D.
Date:  Oct. 14, 1911
Address:  McQuady, Ky
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:  McQuady, Ky
DATE OF BURIAL:  Oct. 14, 1911
20. UNDERTAKER:  E. F. Lyons
ADDRESS:  McQuady, Ky.
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Copyright.  All rights reserved.
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