James H. VIRT Death Certificate

STANDARD CERTIFICATE OF DEATH

INDIANA STATE BOARD OF HEALTH

DIVISION OF VITAL STATISTICS

Local No.: 2

Registered No.: 6613

PLACE OF DEATH:

County: Morgan

Township of: Ashland

Town [blank]

or

City [blank]

No. [blank] St.

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

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

1. FULL NAME: James Virt

Residence: No. [blank] St. [blank]

PERSONAL AND STATISTICAL PARTICULARS:

2. SEX: Male

3. COLOR OR RACE: White

4. Single...: Married

5. NAME OF HUSBAND OR WIFE: Nancy Ellen Virt

6. DATE OF BIRTH: March 15, 1857

7. AGE: 79 years, 10 months, 17 days

OCCUPATION:

8. Trade, profession...: Farmer

9. Industry...: [blank]

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

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

12. BIRTHPLACE: Indiana

FATHER:

13. NAME: Cornelius Virt

14. BIRTHPLACE: Indiana

MOTHER:

15. MAIDEN NAME: Angelina Perkins

16. BIRTHPLACE: Indiana

17. INFORMANT: Nancy E. Virt

(Address): Paragon, Ind

18. PLACE OF BURIAL OR REMOVAL: Paragon

Date: Feb. 7, 19[blank]

19. UNDERTAKER: Paul Begeman

ADDRESS: Paragon

20. WAS THE BODY EMNALMED? Yes

EMBALMER'S LICENSE NO.: 925

21. Filed: Feb 6, 1937

G. S. Silleman, M.D.

Health Officer or Deputy

MEDICAL CERTIFICATE OF DEATH:

22. DATE OF DEATH: Feb. 4, 1937

23. I HEREBY CERTIFY, That I attended deceased from May 1, 1936 to Feb. 4, 1937 and that death occurred, on the date stated above, at 11:31 P.M.

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

Chronic myocarditis

Duration: 2 mos.

Other contributory causes of importance:

Hypotrophy of prostate

Duration: 2 mos.

Chronic cystitis

Duration: 18 mos.

Name of operation: [blank]

Date of: [blank]

What test confirmed diagnosis? [illegible]

Was there an autopsy? [blank]

24. If death was due to external causes... [all questions blank]

25. Was disease or injury in any way related to occupation of deceased? [blank]

(Signed): George S. Selliman, M.D.

Feb. 6, 1937

(Address) : Paragon