1. PLACE OF DEATH
County:  Breckinridge
Vot. Pol.:  Bewleyville
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5313
Primary Registration District No:  
File No.  14270
Registered No:  3
2. FULL NAME:  Booker Shumate
PERSONAL AND STATICAL PARTICULARS
3. SEX:  Female
4. COLOR OR RACE:  White
5. SINGLE, MARRIED, WIDOWED, OR DIVORCED:  Widow
6. DATE OF BIRTH:  June 18, 1911
7. AGE  (yr. mo. da) (If less than 1 day, hours or min?):  69 yrs  3 mos  3 ds
8. OCCUPATION (a.) Trade, profession or particular kind of work:  House Keeper
(b.)  General nature of industry business or establishment which employed:  
9. BIRTHPLACE:  Breckinridge
10. NAME OF FATHER:  Hailing McGriffin
11. BIRTHPLACE OF FATHER:  Breckinridge Co.
12. MAIDEN NAME OF MOTHER:  Ruth Drane
13. BIRTHPLACE OF MOTHER:  Breckinridge Co.
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  E. H. Mitcham
(Address)  Irvington
15. Filed  June 19, 1911
REGISTAR:  John Compton
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH:  June 18, 1911
17. I HEREBY CERTIFY, That I attended deceased from (date):  May 1911 to June 15, 1911
That I last saw him/her alive on (date):  June 15, 1911
And that death occurred on the date stated above at (time AM/PM):  6 p.m.
THE CAUSE OF DEATH was as follows:  Chronic Pneumonia

(Duration)   Years:            Months:  2          Days:  
Contributory:  

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. M. Walker, M.D.
Date:  June 19, 1911
Address:  Irvington
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:  Shumates burial ground
DATE OF BURIAL:  6/19, 1911
20. UNDERTAKER:  Penick Bros
ADDRESS:  Custer, Ky.