1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  12
Inc Town:  Irvington
City:  Irvington
No.  
St.  
Ward:  
Registration District No.:  
Primary Registration District No:  
File No.  213327
Registered No:  5312
2. FULL NAME:  Pate, Virgil Hayes
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  Black
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Single
6. DATE OF BIRTH:  July 31, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  0 yr 6 mo 23 da
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Irvington
10. NAME OF FATHER:  Rutherford H. Pate
11. BIRTHPLACE OF FATHER:  Cloverport, KY
12. MAIDEN NAME OF MOTHER:  Ellen Brown
13. BIRTHPLACE OF MOTHER:  Irvington, KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Rutherford H. Pate
(Address)  Irvington, KY
15. Filed  Feb. 25, 1912
REGISTRAR:  D. W. Henry
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Feb. 24, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Feb. 15, 1912
That I last saw him/her alive on (date):  Feb. 24, 1912
And that death occurred on the date stated above at (time AM/PM):  12 M
THE CAUSE OF DEATH was as follows:  Pneumonida

(Duration)   Years:            Months:            Days:  10
Contributory:  Convulsions

(Duration)   Years:            Months:            Days:  
Signed (M.D.): S. P. Parks
Date:  Feb. 24, 1912
Address:  Irvington, 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:  Irvington, KY
DATE OF BURIAL:  Feb. 25, 1912
20. UNDERTAKER:  G. F. Marshall
ADDRESS:  Irvington