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1. PLACE OF DEATH
County:  Breckenridge
Vot. Pol.:  Balltown
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5321
Primary Registration District No:  
File No.  14881
Registered No:  6
2. FULL NAME:  Mildred J. Pate
PERSONAL AND STATICAL PARTICULARS
3. SEX:  female
4. COLOR OR RACE:  white
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  widowed
6. DATE OF BIRTH:  July 31, 1817
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  96 years, 10 months, 11 days
8. OCCUPATION (a.) Trade, profession or particular kind of work:  House Keeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Don't Know
11. BIRTHPLACE OF FATHER:  Don't Know
12. MAIDEN NAME OF MOTHER:  Mildred J. Weatheholt
13. BIRTHPLACE OF MOTHER:  Ky
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  W. N. Pate
(Address)  Mattingly, Ky
15. Filed  June 13, 1914
REGISTAR:  Fred Franks
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  June 11, 1914
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:  Old Age Determined by Coroners Jury.
                                                                J. J. Keenan  JPBC
 
(Duration)   Years:            Months:            Days:  
Contributory:  
 
(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. J. Keenan, JPBS
Date:  June 12, 1914
Address:  Mattingly, 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:  Patterson Cemetery
DATE OF BURIAL:  June 12, 1914
20. UNDERTAKER:  M. Hammon & Son
ADDRESS:  Cloverport, Ky
 

ADDITIONAL COMMENTS/NOTES:
 
 
 

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