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