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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.:  CUSTER
Inc Town:  
City:  
No.  
St.  
Ward:  
Registration District No.:  5315
Primary Registration District No:  15
File No.  26163
Registered No: 59 
2.	FULL NAME:  SHUMATE, JAMES
PERSONAL AND STATICAL PARTICULARS
3.	SEX:  MALE
4.	COLOR OR RACE:  WHITE
5.	SINGLE, MARRIED, WIDOWED, OR DIVORCED:  MARRIED
6.	DATE OF BIRTH:  FEB 29 1828
7.	AGE  (yr. mo. da) (If less than 1 day, hours or min?):  85 YR 7 MO 16 DA
8.	OCCUPATION (a.) Trade, profession or particular kind of work:  FARMER
(b.)  General nature of industry business or establishment which employed:  
9.	BIRTHPLACE:  MARION CO., KY
10.	NAME OF FATHER:  DANIEL SHUMATE
11.	BIRTHPLACE OF FATHER:  MARION CO., KY
12.	MAIDEN NAME OF MOTHER:  
13.	BIRTHPLACE OF MOTHER:  MARION CO., KY
14.	THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)  GEORGE MILBURN
(Address)  CUSTER, KY
15.	Filed  OCT 17, 1913
REGISTRAR:  J. T. MITCHAM
MEDICAL CERTIFICATE OF DEATH
16.	DATE OF DEATH:  OCT 16, 1913
17.	I HEREBY CERTIFY, That I attended deceased from (date):  MAY 30, 1913
That I last saw him/her alive on (date):  OCT 3, 1913
And that death occurred on the date stated above at (time AM/PM):  6 PM
THE CAUSE OF DEATH was as follows:  CHRONIC GASTRIC CATARRH

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

(Duration)   Years:            Months:            Days:  
Signed (M.D.):  J. A. SANDBACH
Date:  OCT 17, 1913
Address:  GARFIELD, 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:  J. SHOEMATE CEMETERY
DATE OF BURIAL:  OCT 17, 1913
20.	UNDERTAKER:  ALF TAYLOR
ADDRESS:  CUSTER, KY

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Copyright.  All rights reserved.
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