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1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Hardinsburg
Inc Town:  
City:  
No.  
St.  
Ward:  4
Registration District No.:  130
Primary Registration District No:  5304
File No.  30817
Registered No:  
2. FULL NAME:  Lewis Pate
PERSONAL AND STATICAL PARTICULARS
3. SEX:  male
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  single
6. DATE OF BIRTH:  June 8, 1906
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  8 years, 6 months, 13 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  at home
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Allie Pate
11. BIRTHPLACE OF FATHER:  Kentucky
12. MAIDEN NAME OF MOTHER:  Laura Jennings
13. BIRTHPLACE OF MOTHER:  Kentucky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Allie Pate
(Address)  Hardinsburg, Ky
15. Filed  [blank]
REGISTAR:  [blank]
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Dec. 21, 1914
17. I HEREBY CERTIFY, That I attended deceased from (date):  Dec. 21, 1914
That I last saw him/her alive on (date):  
And that death occurred on the date stated above at (time AM/PM):  1 AM
THE CAUSE OF DEATH was as follows:  Measles
 
(Duration)   Years:            Months:            Days:  9
Contributory:  Pneumonia
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  John E. Kincheloe
Date:  Hardinsburg, Ky
Address:  Dec. 21, 1914
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:  St. Romuald Cemetery
DATE OF BURIAL: Dec. 22, 1914
20. UNDERTAKER:  B. F. Beard
ADDRESS:  Hardinsburg, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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