Louisa Ellen NEWBURN (Virt) Death Certificate
INDIANA STATE BOARD OF HEALTH
DIVISION OF VITAL RECORDS
MEDICAL CERTIFICATE OF DEATH
Local No.: [blank]
State No.: 6039
1. PLACE OF DEATH
a. COUNTY: Morgan
b. CITY, TOWN, OR LOCATION: Martinsville
c. Length of Stay on 1b: 3 wks
d. NAME OF HOSPITAL OR INSTITUTION: Morgan Co Hospital
e. IS PLACE OF DEATH INSIDE CITY LIMITS? Yes
2. USUAL RESIDENCE
a. STATE: Indiana
b. COUNTY: Morgan
c. CITY, TOWN, OR LOCATION: Paragon
d. STREET ADDRESS: RR1
e. IS RESIDENCE INSIDE CITY LIMITS? No
f. IS RESIDENCE ON A FARM? Yes
3. NAME OF DECEASED: Louisa Ellen Virt
4. DATE OF DEATH:
Month: 2
Day: 3
Year: 57
5. SEX: Fe
6. COLOR OR RACE: W
7. MARRIED
8. DATE OF BIRTH: Oct 17, 1890
9. AGE (In years last birthday): 66
10a. USUAL OCCUPATION: Housewife
10b. KIND OF BUSINESS OR INDUSTRY: [blank]
11. BIRTHPLACE: Indiana
12. CITIZEN OF WHAT COUNTRY? USA
13. FATHER'S NAME: Peter Newburn
14. MOTHER'S MAIDEN NAME: Ida Stiles
15. WAS DECEASED EVER IN U.S. ARMED FORCES? No
16. SOCIAL SECURITY NUMBER: [blank]
17a. INFORMANT'S NAME: Lorne Virt
17b. INFORMANT'S ADDRESS: RR1 Paragon, Ind
17c. RELATIONSHIP TO DECEASED: Husband
MEDICAL CERTIFICATION:
18. CAUSE OF DEATH
PART I. DEATH WAS CAUSED BY:
IMMEDIATE CAUSE (a): Edema, pulmonary
INTERVAL BETWEEN ONSET AND DEATH: 1 hour
DUE TO (b): Carcinomatosis, generalized
INTERVAL BETWEEN ONSET AND DEATH: 6 months
DUE TO (c): Adenocarcinoma, cecal, primary site
INTERVAL BETWEEN ONSET AND DEATH: 1 yr.
PART II: OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL CONDITION GIVEN IN PART I(a): [blank]
19. WAS AUTOPSY PERFORMED? No
20a. ACCIDENT, SUICIDE, HOMICIDE: [blank]
20b. DESCRIBE HOW INJURY OCCURRED: [blank]
20c. TIME OF INJURY: [blank]
20d. INJURY OCCURRED...: [blank]
20e. PLACE OF INJURY: [blank]
20f. CITY, TOWN, OR LOCATION / COUNTY/ STATE: [blank]
21. ATTENDING PHYSICIAN:
I certify that I attended the deceased from April, 1956 to 2-3-57 and last saw her alive on 2-3-57. Death occurred at 6:55 A.M. (C.S.T.) on the date stated above; and to the best of my knowledge, from the causes stated.
22. HEALTH OFFICER
I certify that I investigated cause of death of deceased and find that death occurred at [blank] M. (C.S.T.) from causes stated and on above date.
23a. Signature of Attending Physician or Health Officer: James C. Farr M.D.
23b. ADDRESS: Paragon, Ind.
23c. DATE SIGNED: 2-6-57
24a. BURIAL, CREMATION, REMOVAL: Burial
24b. DATE: 2-5-57
24c. NAME OF CEMETERY OR CREMATORY: Friendship Pk.
24d. LOCATION: Paragon, Ind
DATE REC'D BY LOCAL HEALTH OFFICER: 2-5-57
SIGNATURE OF HEALTH OFFICER: D. A. Eisenburg
25. FUNERAL DIRECTOR: Cure Hensley
ADDRESS: Martinsville Ind
Transcription by John C. Hepner, 1999