America Ann BASTIN (Bolin) Death Certificate

INDIANA STATE BOARD OF HEALTH

Division of Vital Records

CERTIFICATE OF DEATH

Local No.: [blank]

Death No.: 19978

1. PLACE OF DEATH:

a. County: Morgan

b. CITY OR TOWN: Paragon Ind.

c. FULL NAME OF HOSPITAL OR INSTITUTION: [blank]

2. USUAL RESIDENCE:

a. STATE: Ind

b. COUNTY: Morgan

c. CITY OR TOWN: Paragon, Ind

d. STREET ADDRESS: [blank]

3. NAME OF DECEASED: Anna Bolin

4. DATE OF DEATH: June 11, 1951

5. SEX: White

6. COLOR OR RACE: Female

7. MARRIED . . .: Widow

8. DATE OF BIRTH: July 6, 1863

9. AGE: 88 years, [blank] months, [blank] days

10a. USUAL OCCUPATION: [blank]

10b. KIND OF BUSINESS: House work

11. BIRTHPLACE: Indiana

12. CITIZEN OF WHAT COUNTRY? U.S.A.

13. FATHER'S NAME: Anderson Bastin

14. MOTHER'S MAIDEN NAME: Elizabeth McDaniel Bastin

15. WAS DECEASED EVER IN U.S. ARMED FORCES? [blank]

16. SOCIAL SECURITY NO.: [blank]

17. INFORMANT: Edith Bolin, Paragon, Ind

18. CAUSE OF DEATH

I. DISEASE OR CONDITION DIRECTLY LEADING TO DEATH: Chronic myocarditis

INTERVAL BETWEEN ONSET AND DEATH: 4 yrs.

ANTECEDENT CAUSES: [blank]

II. OTHER SIGNIFICANT CONDITION: Probable cancer of colon

INTERVAL BETWEEN ONSET AND DEATH: ?

19a. DATE OF OPERATION: [blank]

19b. MAJOR FINDING OF OPERATION: [blank]

20. AUTOPSY? No

21a. TIME OF INJURY: [blank]

21b. INJURY OCCURRED: [blank]

21c. HOW DID INJURY OCCUR? [blank]

22a. ATTENDING PHYSICIAN

I certify that I attended the deceased from May 12th 1951 to June 11th 1951, and that death occurred at 3: P.M. from causes stated and on above date.

22b. HEALTH OFFICER

I certify that I investigated cause of death of deceased and that that death occurred at 3 P.M. from causes stated and on above date.

23a. Signature of Attending Physician or Health Officer: Leon Gray, M.D.

23b. ADDRESS: Martinsville Ind

23c. DATE SIGNED: 6/12 51

24a. BURIAL, CREMATION, REMOVAL: Burial

24b. DATE: June 13, 1951

24c. NAME OF CEMETERY OR CREMATORY: Paragon I.O.O.F.

24d. LOCATION: Paragon Ind.

DATE REC'D BY LOCAL HEALTH OFFICER: 6-15-51

SIGNATURE OF HEALTH OFFICER: D. A. Eisenburg, MD

25. FUNERAL DIRECTOR: Paul Begeman

ADDRESS: [blank]

FUNERAL DIRECTOR'S LICENSE No.: 925

EMBALMER'S NAME: Dwight Payne

LICENSE No. 2804