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File contributed for use in USGenWeb Archives by:
Dana Brown http://www.genrecords.net/emailregistry/vols/00005.html#0001067
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1. PLACE OF DEATH
County:  Breckinridge	
Vot. Pol.:  5307
Inc Town:  Cloverport
City:  
No.  
St.  
Ward:  3
Registration District No.:  5307
Primary Registration District No:  131
File No.  8814
Registered No:  9
2. FULL NAME:  William Louis Pate
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Male
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Married
6. DATE OF BIRTH:  Feby. 16, 1835
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  76 yrs  2 mox
8. OCCUPATION (a.) Trade, profession or particular kind of work:  Farmer
(b.)  General nature of industry business or establishment which employed:  Farm work
9. BIRTHPLACE:  Kentucky
10. NAME OF FATHER:  Jerry Pate
11. BIRTHPLACE OF FATHER:  Virginia
12. MAIDEN NAME OF MOTHER:  Polly Ball
13. BIRTHPLACE OF MOTHER:  Virginia
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  T. W. Pate
(Address)  Cloverport, Ky
15. Filed  April 16, 1911
REGISTAR:  J. C. Nolte
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  April 16, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  April 5, 1911 to April 16, 1911
That I last saw him/her alive on (date):  April 5, 1911
And that death occurred on the date stated above at (time AM/PM):  3 a.m.
THE CAUSE OF DEATH was as follows:  Cerebral Hemarrage

(Duration)   Years:            Months:            Days:  
Contributory:  Old age

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  E. C. McDonald  M.D.
Date:  April 16, 1911
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:  Pisgah Burying Ground
DATE OF BURIAL:  Apr. 17, 1911
20. UNDERTAKER:  M. Hamman & Son
ADDRESS:  Cloverport, Ky.

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Copyright.  All rights reserved.
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