1. PLACE OF DEATH
County: Breckinridge
Vot. Pol.:  5307
Inc Town:  Cloverport, KY
City:  
No.  
St.  
Ward:  3
Registration District No.:  
Primary Registration District No:  
File No.  6180
Registered No:  55
2. FULL NAME:  Pate, Wilbert
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  
6. DATE OF BIRTH:  Mar 23, 1912
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  
8. OCCUPATION (a.) Trade, profession or particular kind of work:  
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge Co., KY
10. NAME OF FATHER:  Helmer Pate
11. BIRTHPLACE OF FATHER:  Breckinridge Co., KY
12. MAIDEN NAME OF MOTHER:  Tillie Tindall
13. BIRTHPLACE OF MOTHER:  Breckinridge Co., KY
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  Halmer Pate
(Address)  Cloverport, KY
15. Filed  Mar 23, 1912
REGISTRAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  Mar 23, 1912
17. I HEREBY CERTIFY, That I attended deceased from (date):  Mar 23, 1912
That I last saw him/her alive on (date):  Mar 23, 1912
And that death occurred on the date stated above at (time AM/PM):  7:30 am
THE CAUSE OF DEATH was as follows:  Premature birth

(Duration)   Years:            Months:            Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. C. McDonald
Date:  Mar 23, 1912
Address:  Cloverport, 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:  Tindall Burying Ground
DATE OF BURIAL:  Mar 23, 1912
20. UNDERTAKER:  James Tindall
ADDRESS:  Cloverport, KY