USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 141
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State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, eryslpelas, meningitis, miscar- rlage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an uudertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as re- quired by seetion one, where same was eontraeted, the duration of his last illness, when last seen alive by the physician or officer and tho date of his death. . ..- Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent . . . or .. . from the clerk of the town where the person died; . . . No such permit shall be issued until there shall have been delivered to such board, agent or clerk ... a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certi- fieate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be 'obtained early enough for the purpose, or is insufficient, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certi- ficate. .. . The person to whom the permit is so given and the physi- cian certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of tho death, which the clerk or registrar may require. - Gen. Laws, Chap. 114, Sec. 45.
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence. - Gen. Laws, Chap. 38, Sec. 6.
. . . He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residence, if known; other- wise a description as full as may be, with the causo and manner of death. -Gen. Lows, Chap. 38, Sec. 7.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physiclans will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persone found dead.
bc
UNITED STATES GOVERNMENT WAR DEPARTMENT QUARTERMASTER CORPS GRAVES REGISTRATION SERVICE PIER 2 HOBOKEN N. J.
October 24 th 1921.
TRANSPORTATION OF CORPSE
PERMISSION IS HEREBY GRANTED TO CONVEY THE BODY OF THE FOLLOWING NAMED PERSON, WHO DIED OVERSEAS IN THE SERVICE OF THE UNITED STATES, FROM HOBOKEN, N. J. TO WINTHROP, MASSACHUSETTS AND SOLDIER ESCORT IS HEREBY AUTHORIZED TO ACCOMPANY SAID BODY IN TRANSIT.
FULL NAME OF DECEASED NELLIGAN, WILLIAM P. CPL. 60036
CAUSE OF DEATH KA Cc. B, 101st Inf.
DATE OF DEATH 10-24-18
DEATH OCCURRED ON DATE STATED ABOVE WHILE SERVING WITH THE UNITED STATES ARMY IN FRANCE.
BODY DISINTERRED BY THE UNITED STATES GOVERNMENT IN FRANCE . 1
THIS BODY HAS BEEN PREPARED IN ACCORDANCE WITH THE REGULATIONS OF THE DEPARTMENT OF HEALTH OF THE STATE OF NEW JERSEY, AND THE ISSUANCE OF THIS PERMIT HAS BEEN APPROVED BY THE SAID DEPARTMENT.
R. E. SHANNON, CAPTAIN, Q.M.C. ,U.S.A .. OFFICER IN CHARGE.
1 PLACE OF DEATH
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
State of.
massachusetts
Registered No.
[If death occurred In a hospital or Institution, give Its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
mali
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Single
6 DATE OF BIRTH
September 6 1896
(Month)
(Day)
(Year)
7 AGE 22
yrs
1
mos
19.
ds.
If LESS than
1 day, ____ hrs.
or .___. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Soldier
(b) General nature of Industry,
business, or establishment in
which employed (or employer)
U. S. army
9 BIRTHPLACE
(State or country)
Danby Hermont
10 NAME OF
FATHER
Frank La Batt
11 BIRTHPLACE
OF FATHER
(State or country)
Massachusetts
12 MAIDEN NAME
OF MOTHER
Lillian La Batt
13 BIRTHPLACE
OF MOTHER
(State or country)
New york
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mr Lillian La Batt
(Address)
arlington, It
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
October
(Month) 20- 1918
(Day) (Year)
17
I HEREBY CERTIFY, That I attended deceased from
Sept 21st
191.X
Lact 25kg
, to
191,
Cort 25"
that I last saw h_2222 alive on
191 ... ,
and that death occurred, on the date stated above, at
7.03 m.
The CAUSE OF DEATH* was as follows:
Pneumoniae Robar
(Duration)
yrs.
Menos.
4
ds.
( SECONDARY)
Theunion (uration)
yrs.
mos.
ds.
(Signed)
a.K. Stanword
M. D.
Oct 25
191-9_
(Address)
Fort Banks
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS OF INJURY ; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS)
At place
of death
yrs.
In the
mos.
ds. State
yrs.
mos.
ds.
Where was dlsease contracted, if not at place of death ?
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL arlington Vt.
DATE OF BURIAL
11/28
1918
20 UNDERTAKER
C. R. Bennizan
ADDRESS
Wintherof
15 important. See instructions on back of certificate. N. B .- Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIENS should stato CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very PARENTS
County
Just Hospital
Township
Front Banks
Winthrop
Village
or
City
2 FULL NAME
Amass (No Post Stort, Ft. Bankens Mas Ward)
Haskin, La Batt
11-3184
Contributory.
Jokeinea following
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation .- Precise statement of oceupation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples : (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," " Dealer," cte., without more precise specification, as Day laborer, Farm laborer, Laborer-Coul mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekcepers who receive a definite salary), may be entered as Housewife, Houscwork, 02 .At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state oeeupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no oceupation whatever, write Nonc.
Statement of cause of death .- Name, first, the DISEASE CAUS- ING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefi- nite); Tuberculosis of lungs, meninges, peritonaeum, etc., Car- cinoma, Sarcoma, etc., of . - (name origin; “Can- cer" is less definite; avoid use of " Tumor" for malignant neoplasms); Mcasles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The eon- tributory (secondary or intercurrent) affection need not be stated unless important. Example : Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal eondi- tions, such as "Asthenia," "Anaemia" ( merely symptom-
atie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inani- tion," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be ascer- tained as the eause. Always qualify all diseases result- ing from ehildbirth or misearriage, as "PUERPERAL septi- chaemia," "PUERPERAL peritonitis," etc. State eause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train-accident; Revolver wound of head- homicide ; Poisoned by carbolic acid-probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated under the head of "Contributory." (Recommendations on statement of eause of death approved by Committee on Nomenclature of the American Medical Association. )
NOTE .- Individual offices may add to above list of undesirable terms and refuse to accept certificates containing them. Thus the form in use in New York City states: "Certificates will be returned for additional information which give any of the following discases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, haemorrhage, gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, pyaemia, septichaemia, tetanus." But general adoption of the minimum list suggested will work vast improvement, and its scope can be extended at a later date.
11-3184
UNITED STATES GOVERNMENT WAR DEPARTMENT QUARTERMASTER CORPS GRAVES REGISTRATION SERVICE PIER 2 HOBOKEN N. J.
tg
- Oct.9, 1921.
TRANSPORTATION OF CORPSE
PERMISSION IS HEREBY GRANTED TO CONVEY THE BODY OF THE FOLLOWING NAMED PERSON, WHO DIED OVERSEAS IN THE SERVICE OF THE UNITED STATES, FROM HOBOKEN, N. J. TO WINTHROP, MASSACHUSETTS AND SOLDIER ESCORT IS HEREBY AUTHORIZED TO ACCOMPANY SAID BODY IN TRANSIT.
FULL NAME OF DECEASED DONOVAN, Simon J., Pvt. M.G.Co., 101st Inf. 62955
CAUSE OF DEATH DWRIA DATE OF DEATH 10/25/18
DEATH OCCURRED ON DATE STATED ABOVE WHILE SERVING WITH THE UNITED STATES ARMY IN FRANCE.
BODY DISINTERRED BY THE UNITED STATES GOVERNMENT IN FRANCE.
THIS BODY HAS BEEN PREPARED IN ACCORDANCE WITH THE REGULATIONS OF THE DEPARTMENT OF HEALTH OF THE STATE OF NEW JERSEY, AND THE ISSUANCE OF THIS PERMIT HAS BEEN APPROVED BY THE SAID DEPARTMENT.
R. E. SHANNON. CAPTAIN, Q.M.C., U.S.A .. OFFICER IN CHARGE.
STANDARD 25
R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
BOSTON (City or Town)
1 PLACE OF DEATH County ..
Suffolk
State Massachusetts
Registered No.
271
City or Town
No.
france
St., ..........
Ward
(If death occurred iu a hospital or institution, give its NAME instead of street and number) - the 101 st lat
(If in the Army or Navy of the United States, give rank, organization, etc.)
(If nou-resident give city or town and State)
( Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How loog in U. S., if of foreign hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Mute Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH Mar. 23. 1900
(Month)
(Day)
(Year)
Years
7 AGE 18
Months
7
Days
If LESS than 1 day ......... hrs. or ....... min.
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Soldier
.(duration)
yrs.
mos.
ds.
CONTRIBUTORY ( SECONDARY)
(duration)
yrs
mos.
.. ds.
18 Where was disease contracted if not at place of death ? FOR WHAT ?
Sohn Banana Did an operation precede death?
11 BIRTHPLACE OF
FATHER ( Vitý ).
(State or country)
12 MAIDEN NAME
OF MOTHER
batterque donovan
( Address).
Date.
(Month)
( Day)
(Year)
19 PŁACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
(Cemetery)
(City or town)
20 UNDERTAKER ichand laterdu
ADDRESS
Cast Boston
Filed (Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from
, 19 ... ....... , to. 19
that I last saw h ... ...... alive on 19
and that death occurred, on the date stated above, at
.m.
The CAUSE OF DEATH was as follows :
Died how wounds received
in action in France
.... . Date of.
Was there an autopsy ?
Gast Bratan What test confirmed diagnosis ?
M.D.
13 BIRTHPLACE OF MOTHER (City) (State or country) battuccini Nous
Catherine Mccormack Holy Close
Informant
(Address)
2) Real t
15 Oct. 14, 1921
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was Gled with me BEFORE the burial or transit permit was issued J. a. Poury
Official position.
Health Offices
Date of issue of permit act. 12.
Permit No 838
XM. 000
The Commonwealth of Massachusetts
8
2 FULL NAME
(a) Residence.
No.
30 Beach
St.,
Ward.
October 25, 8.
3 SEX 10 NAME OF FATHER PARENTS 14 instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (h) Name of employer
9 BIRTHPLACE (City)
(State or country)
masq
REVISED UNITED STATES STANDARD CERTIFI OF DEATH LApproved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (tho primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualifiec. 's indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of ...... . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not bo stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," otc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as re- quired by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . ..- Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury a human body .. . until he has received a permit from the board of health or its agent . . . or . . . from the clerk of the town where the person died; . . . No such permit shall be issued until thereshall have been delivered to such board, agent or clerk ... a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certi- ficate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certi- ficate. ... The person to whom the permit is so given and the physi- cian certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Gen. Laws, Chap. 114, Sec. 45.
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence. - Gen. Laws, Chap. 38, Sec. 6.
. . . Ho shall in all cases certify to the town clerk or registrar in the place where the deceased dicd his name and residence, if known; other- wise a description as full as may be, with the cause and manner of death. - Gen. Laws, Chap. 38, Sec. 7.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have dicd without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
Harvard (City or town)
1 PLACE OF DEATH
Registered No ..
630 (Place of death)
County
......
War
State inass.
Registered No ..
City or Town
Harvard
o. Base Aash @ Deveres.
St.,
Ward
2 FULL NAME
Chandler 86. Cabey
(If death occurred in a hospital or institution, give its NAME instead of street and number)
but co3 2 ml
(a) Residence. State
(Usual place of abode)
mars
City or Town
Unichroh
No.
My Banklet Ras.
Length of residence in city or town where death occurred
years
months
days
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5,
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) June 6 "1895
7 AGE
Years
2 3
Months
Days
If LESS than
I day ......... brs. or ....... min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work.
Folder
(b) General nalore of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Chelsea
(State or country) mars
10 NAME OF FATHER Benjamin 2.
PARENTS
11 BIRTHPLACE OF FATHER (city or town) (State or country) marie
12 MAIDEN NAME OF MOTHER Eva Sinclair
13 BIRTHPLACE OF MOTHER (city or town) (State or country) Mars
stcollection ..... (Sigoed)
14
Informant (Address)
15
Filed
, 19 8 JS Winter
Registrar of city or town where death occurred
Filed 71-0.0. 4
19. 8
Registrar of city or town where deceased resided
16 DATE OF DEATH (month, day, and year)
27
19/8
17
I HEREBY CERTIFY, That I attended deceased from
2/
19 ......
8,
to
19.2.
that I last saw b- Malive on
2'1
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