Nancy Ellen BURKHARDT (Virt) Death Certificate

STANDARD CERTIFICATE OF DEATH

INDIANA STATE BOARD OF HEALTH

DIVISION OF VITAL STATISTICS

Local No.: [blank]

Registered No.: 9962

1. 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.

2. FULL NAME: Nancy Ellen Virt

Residence: No. [blank] St.

PERSONAL AND STATISTICAL PARTICULARS:

3. SEX: Female

4. COLOR OR RACE: White

5. Single...: Widow

a. NAME OF HUSBAND OR WIFE: Jame Virt

b. "Deceased"

6. DATE OF BIRTH: Jan 16, 1856

7. AGE: 83 years, 1 months, 22 days

OCCUPATION:

8. Trade...: House Keeper

9. Industry...: [blank]

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

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

12. BIRTHPLACE: Indiana

FATHER:

13. NAME: Ambros Burkhart

14. BIRTHPLACE: Indiana

MOTHER:

15. MAIDEN NAME: Anna Bragg

16. BIRTHPLACE: Tennessee

17: INFORMANT: Loren Virt

(Address): Paragon, Ind

18. PLACE OF BURIAL OR REMOVAL: Paragon

Date: Mar. 12, 1939

19. UNDERTAKER: Paul Begeman

ADDRESS: Paragon

20. WAS THE BODY EMBALMED? Yes

EMBALMER'S LICENSE NO.: 925

21. Filed 3-13-1939

Claude T. White

Health Officer or Deputy

MEDICAL CERTIFICATE OF DEATH:

22. DATE OF DEATH: March 10, 1939

23. I HEREBY CERTIFY, That I attended deceased from Feb. 17 1939 to Mar. 10 1939 and that death occurred, on the date stated above, at 4 A.M.

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

Chronic MyoCarditis

Duration: 3 yrs.

Other contributory causes of importance:

Arteriosclerosis

Duration: unknown

Name of operation: [blank]

Date of: [blank]

What test confirmed diagnosis? [blank]

Was there an autopsy? No

24. If death was due to external causes (violence) fill in also the following:

Accident, suicide, or homicide? [blank]

Date of injury: [blank] 19[blank]

Where did injury occur? [blank]

Specify whether injury occurred in industry, in home, or in public place: [blank]

Manner of injury: [blank]

Nature of injury: [blank]

25. Was disease or injury in any way related to occupation of deceased? No

(Signed) L. M. Hughes, M.D.

Mar 10, 1939

(Address) Paragon, Ind.