Emanuel Eli Bolin Death Certificate

Indiana State Board of Health

CERTIFICATE OF DEATH

PLACE OF DEATH

County of: Morgan

Township of: Ray

Town of: Paragon

Or

City of [blank] (No. [blank], [blank] St.; [blank] Ward)

Registered No.: 19246

FULL NAME: Emanuel Bolin

PERSONAL AND STATISTICAL PARTICULARS

SEX: Male

COLOR OR RACE: White

SINGLE, MARRIED . . .: Married

NAME OF HUSBAND OR WIFE: America Bolin

DATE OF BIRTH: May 14, 1856

AGE: 66 years, 1 months, 4 days

OCCUPATION:

(a) Trade . . .: Laborer Retired

(b) General nature of industry . . .: [blank]

BIRTHPLACE OF DECEASED: Indiana

PARENTS:

NAME OF FATHER: Christopher Bolin

BIRTHPLACE OF FATHER: Kentucky

MAIDEN NAME OF MOTHER: Amanda Guy

BIRTHPLACE OF MOTHER: North Carolina

THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant) America Bolin

(Address) Paragon Ind.

MEDICAL CERTIFICATE OF DEATH

DATE OF DEATH: June 18, 1922

I HEREBY CERTIFY, that I attended deceased from May 1st, 1922 to June 18, 1922, that I last saw him alive on June 18, 1922, and that death occurred, on the date stated above, at 3 P.M.

The CAUSE OF DEATH was as follows:

Chronic Valvular disease of heart

Contributory [blank]

(Signed) Uriah H. [?] Farr, M.D.

June 19, 1922

(Address) Paragon, Ind.

LENGTH OF RESIDENCE: [blank]

PLACE OF BURIAL OR REMOVAL: Paragon Ind. I.O.O.F.

UNDERTAKER: Paul Begeman

ADDRESS: Paragon Ind.

DATE OF BURIAL: June 20, 1922

WAS THE BODY EMBALMED? Yes

EMBALMER'S LICENSE NO.: 925

[File date and name and address of health officer are blank]