1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  5307
Inc Town:  
City:  Cloverport
No.  
St.  
Ward:  3
Registration District No.:  
Primary Registration District No:  
File No.  8229
Registered No:  56
2. FULL NAME:  Pate, Tilda
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  Oct 14, 1894
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  17 yr 5 mo 29 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Housekeeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  KY
10. NAME OF FATHER:  James H. Tindall
11. BIRTHPLACE OF FATHER:  Indiana
12. MAIDEN NAME OF MOTHER:  Authy C. Roberts
13. BIRTHPLACE OF MOTHER:  KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  James Tindall
(Address)  Cloverport
15. Filed  Apr 13, 1912
REGISTRAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Apr 13, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Apr 10, 1912
That I last saw him/her alive on (date):  Apr 11, 1912
And that death occurred on the date stated above at (time AM/PM):  3 am
THE CAUSE OF DEATH was as follows:  Puerperal fever

(Duration)   Years:            Months:            Days:  21
Contributory:  Strumous diathesis

(Duration)   Years:            Months:            Days:  Since childhood
Signed (M.D.):  F. L. Lightfoot
Date:  Apr. 13, 1912
Address:  Cloverport
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:  Breckinridge Co., KY
DATE OF BURIAL:  Apr 14, 1912
20. UNDERTAKER:  M. Hammon Sons
ADDRESS:  Cloverport, KY