Emma Letta WHITESITT (Virt) Death Certificate

CERTIFICATE OF DEATH

STATE OF INDIANA

DIVISION OF PUBLIC HEALTH

BUREAU OF VITAL STATISTICS

Local No.: 362

Registered No.: 3788

1. PLACE OF DEATH:

County of: Owen

Township of: Wayne

Town: Gorfort Ind.

or

City: [blank] No. [blank] St.

Length of residence in city or town where death ocurred: [blank] yrs. [blank] mos. [blank] ds.

How long in U.S. if foreign birth? [blank] yrs. [blank] mos. [blank] ds.

2. FULL NAME: Emma Letta Virt

Residence:

No.: 19 yrs. Gorfort Ind

St.: [blank]

PERSONAL AND STATISTICAL PARTICULARS:

3. SEX: Female

4. COLOR OR RACE: white

5. Single...: married

5a. NAME OF HUSBAND OR WIFE: Harry F. Virt

6. DATE OF BIRTH: June 11, 1866

7. AGE: 68 years, 4 months, 23 days

OCCUPATION:

8. Trade...: House Wife

9. Industry...: [blank]

10. Date deceased last worked at this occupation: [blank]

11. Total time (years) spent: [blank]

12. BIRTHPLACE: Indiana

FATHER:

13. NAME: William H. Whitesitt

14. BIRTHPLACE: Indiana

MOTHER:

15. MAIDEN NAME: Myria Seff

16. BIRTHPLACE: Indiana

17. INFORMANT: Mr. J. O. McGinness

(Address) Gorfort Ind R.F. Del.

18. PLACE OF BURIAL OR REMOVAL: I.O.O.F. Cemetery, Paragon

Date: Jan 6, 1934

19. UNDERTAKER: Ernest G. Dorsett

(ADDRESS) Gorfort

20. WAS THE BODY EMBALMED? yes

EMBALMER'S LICENSE NO.: 1909

21. Filed: Jan 7, 1935

Health Officer or Deputy: Pauline J. Bra... [illegible]

MEDICAL CERTIFICATE OF DEATH:

22. DATE OF DEATH: Jan 4, 1935

I HEREBY CERTIFY, That I attended deceased from November 1, 1934 to Jan. 4, 1935 and that death occurred, in the date stated above, at 9:30 pm

The principal cause of death and related causes of importance were as follows:

Obstructive jaundice

Duration: 3 months

Other contributory causes of importance:

Gallstones

Duration: ? years

Name of operation: [blank]

Date of: [blank]

What test confirmed diagnosis? [blank]

Was there an autopsy? [blank]

23. If death was due to external causes (violence) fill in also the following: [all blank]

(Signed) Julia Thom, M.D.

Jan. 5, 1935

(Address) Gorfort, Ind.