Lorne VIRT Death Certificate

INDIANA STATE BOARD OF HEALTH

CORONER'S CERTIFICATE OF DEATH

Local No.: 72-142

Death No.: 72-031213

DECEASED:

1. NAME: Lorne Virt

2. SEX: male

3. DATE OF DEATH (MONTH, DAY, YEAR): 8/7/1972

4. RACE: white

5a. AGE-LAST BIRTHDAY (Years): 80

5b. UNDER 1 YEAR: [blank]

5c. UNDER 1 DAY: [blank]

6. DATE OF BIRTH (MONTH, DAY, YEAR): 4/1/92

7a. COUNTY OF DEATH: Morgan

7b. CITY, TOWN, OR LOCATION OF DEATH: Paragon

7c. INSIDE CITY LIMITS? yes

7d. HOSPITAL OR OTHER INSTITUTION (IF NOT IN EITHER, GIVE STREET AND NUMBER: Main St. Paragon, Ind.

8. STATE OF BIRTH: Indiana

9. CITIZEN OF WHAT COUNTRY: US

10. MARRIED...: widowed

11. SURVIVING SPOUSE: [blank]

12. SOCIAL SECURITY NUMBER: 306-36-2032

13a. USUAL OCCUPATION: Farmer

13b. KIND OF BUSINESS OR INDUSTRY: [blank]

14a. RESIDENCE-STATE: Indiana

14b. COUNTY: Morgan

14c. CITY, TOWN OR LOCATION: Paragon

14d. INSIDE CITY LIMITS: yes

14e. TOWNSHIP: Ray

14f. STREET AND NUMBER: [blank]

14g. WAS DECEASED EVER IN U.S. ARMED FORCES? yes. WW # 1

14h. RESIDENCE ON A FARM? No

PARENTS:

15. FATHER-NAME: James Virt

16. MOTHER-MAIDEN NAME: Nancy Ellen Burkhart

17a. INFORMANT-NAME: Mrs. Shirley Bastin (overtyped "i" and "o" in Bastin)

17b. RELATIONSHIP: daughter

17c. MAILING ADDRESS: Paragon, Indiana

CAUSE:

Part I: DEATH WAS CAUSED BY:

18. IMMEDIATE CAUSE

(a) Congestive Heart Failure

DUE TO, OR AS A CONSEQUENCE OF:

(b} Arteriosclerotic Heart Disease

Part II: OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (A): [blank]

19a. AUTOPSY: no

19b. IF YES...: [blank]

20a. ACCIDENT, SUICIDE, HOMICIDE, OR UNDETERMINED: [blank]

20b. DATE OF INJURY: [blank]

20c. HOUR: [blank]

20d. HOW INJURY OCCURRED: [blank]

20e. INJURY AT WORK: [blank]

20f. PLACE OF INJURY: [blank]

20g. LOCATION: [blank]

CERTIFIER:

CORONER'S CERTIFICATION

ON THE BASIS OF THE EXAMINATION OF THE BODY AND/OR THE INVESTIGATION, IN MY OPINION, DEATH OCCURRED ON THE DATE AND DUE TO THE CAUSE(S) STATED.

21a. DEATH OCCURRED (HOUR): unk

21b. THE DECEDENT WAS PRONOUNCED DEAD: Aug. 7, 1972, 4:30 p.m.

21c. DATE SIGNED (MONTH, DAY, YEAR): 8/8/1972

22a. CERTIFIER-NAME: Thomas E. Neal

22b. SIGNATURE: Thomas E. Neal

(DEGREE OR TITLE: coroner

23. MAILING ADDRESS-CERTIFIER: 110 E. Poston Rd, Martinsville, Indiana 46151

BURIAL:

24a. BURIAL, CREMATION, REMOVAL: Burial

24b. CEMETERY, CREMATORY, FUNERAL HOME: Friendship Park Cemetery

24c. LOCATION: Paragon, Indiana

24d. DATE (MONTH, DAY, YEAR): 8/10/1972

25a. FUNERAL HOME-NAME AND ADDRESS: Neal & Summers, 110 E. Poston Rd., Martinsville, Ind. 46151

25b. [blank]

26a. SIGNATURE OF HEALTH OFFICER: K. E. Conn, M.D.

26b. DATE RECEIVED BY LOCAL HEALTH OFFICER: 8-8-72