USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 11
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(c) Name of employer
(duration)
..... yrs.
.mos.
ds.
CONTRIBUTORY.
(SECONDARY)
(duration)
mos ........... .ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ?.
Date of
Was there an autopsy ?.
What test confirmed diagnosis ?.
(Signed) .
W. Y. Bryan
... , M.D.
/25. 19/9 (Address) Hathor M ass.
14
Unistis Roch
Informant
(Address)
Hathorne Wase.
15
File
Je 26. 1919 Julius ONale
Feb. 26
Registrar of city or town where death occorred
Filed
19
Registrar of city or towo where deceased resided
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Winthro um, Winthro
DATE OF BURIAL Jeb 26 1919
20 UNDERTAKER
ADDRESS
William 6. Skaggs, Winthrop
MARGIN REOLKYED TOR DINDING
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every Item of information should be so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Austria
12 MAIDEN NAME OF MOTHER unknown
2.
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Austra
17 I HEREBY CERTIFY, That I Attended deceased from Salat. 27
19.
18, to grab, 23
1919.
that I last saw him
alive on
23
1919
and that death occurred, on the date stated above, 12-40 0 m. The CAUSE OF DEATH" was as follows:
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.) Smural Paralysis of the Insane
9 BIRTHPLACE (city or town)
(State or country)
Austria
10 NAME OF FATHER August Belinski
State Mass.
County
City or Town
Aurel Belinski
......
(If in the Armyor Navy of the United States, give rank, organization, etc.)
(a) Residence.
State
(Usual place of abode)
16 DATE OF DEATH (month, day, and year)
Fiat. 23
19/
February 23,199
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cacli 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, Architcet, 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) Forcman, (b) Automobile factory. The ma- terial 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 household 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- eifically the occupations of persons engaged in domestic 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 occupation at beginning of illness. If retired from business, that fact may be indi- cated thius: Farmer (retired, 6 yrs.). For persons who liave no occupation whatever, write Nonc.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATII (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); 'Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Cancer" is less definite; avoid use of "'Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Astlicnia," "Anemia" (Increly symptomatic), "Atrophy," "Col- Гарse," "Coma," "Convulsions,"" "Debility" ("Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock,"" "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ctc. State cause 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 de- termine 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or one supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 303. 6-'18. 50,000.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town)
1 PLACE OF DEATH
County
Suffolk
Township
Anthropo
State
Massachusetts
.Registered No.
City ..
BOSTON
No.
28 Oakland
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
mara
"ttfittheirmyor
No. 20/ aplana
St.,
Ward.
(Usual place of abodes
Leogth of residence in city or town where death occurred
years
mooths
days.
How long io U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Semale Heute
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE Years
Months
10
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
(b) General oature of industry, business, or establishmeot io which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Tanthof
(State or country)
10 NAME OF FATHER Dred
PARENTS
11 BIRTHPLACE OF FATHER (city er town)
(State or country)
12 MAIDEN NAME OF MOTHER margaretm &
13 BIRTHPLACE OF MOTHER (city or toyn) (State or country)
Everett
14
Informant Father Fred.
(Address)
15
Filed Feb.28, 1919
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Feb 96 19
17
I HEREBY CERTIFY, That I attended deceased from
Fef 12
19.19
to.
T2625
19 09
that I last saw her
alive on
Feb 26
1917
and that death occurred, on the date stated above, at
1 a
m.
The CAUSE OF DEATH* was as follows :
J. b. Manin us
(duration)
.yrs ...........
.. mos.
1
ds.
CONTRIBUTORY
Firenza
(SECONDARY)
(duration)
yrs ..
mos.
ds.
18 Where was disease contracted
if not at place of death ?
FOR WHAT?
Did an operation precede death ?
Date of
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed)
M.D.
17 19, 24(Address)
562
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURE, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Holy Cross Dny
20 UNDERTAKER
ADDRESS
or Village.
Good Bouton
or
(a) Residence.
(If non-resident give city or town and State)
4 COLOR OR RACE
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion 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, Architeet, 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," 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 household 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, etc. 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 indi- cated 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 (the primary affection with respect to time and causation), using always the same accepted term for the saine disease. Examples: Cerebrospinal fcver (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, 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 be stated unless important ..... Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Ancmia" (inerely symptomatic), "Atrophy," "Col-
lapse," "Coma," "Convulsions,"" "Debility" (“Con- genital," "Senile," etc.), "Dropsy." "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ctc. State cause 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 de- termine 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
Registrar.
this is a true copy of the certificate received for record. Thomas Steel est,
State of Connecticut BUREAU OF VITAL STATISTICS
COPY
Medical Certificate of Death
1. Full name of deceased
Margaret Dou Las
UNH · SUL. 7
2. Primary cause of death
Cerebro: He orwhere
3. Duration
days
4. Secondary or contributory
5.
Duration
days
Remarks
Had cerebral hemorrhage 4 months ago, pracu ly failed since.
I Certify that I attended the deceased in h .. e .....
last illness, and that the cause of death
was as above stated.
Signature
2. Hanrahan, M.D.
Capacity in which he signs
Dated
March Ist.
19 19
Address.
Bristol, onn.
Undertaker's Certificate PERSONAL AND STATISTICAL
1. Full name of deceased
Margaret Porlas
2. Place of death-Town
Eric tol
No.
498 West
Street, Ward.
[If death occurred in a hospital or institution. give its name instead of street and number]
3. Number of families in house
4. Residence at time of death inthrone, dass.
5. Occupation
At home
Town
State or Country
6. Condition (state whether single. married, divorced or widowed) widow
7. If wife or widow, give name of husband
Alexander -725
8. Date of death-year
1838
7970
month
March
7
, day
9. Date of birth -year
80
, month
Der.
, day
7
10. Age
years,
3
months,
days
11. Sex female
12. Color hite
13. Birthplace-Town ........... Justone
State or Country.
Scotien
This Certificate received for record on the Ist day of March 19 79
Registrar. Imma . Fish, isst.
Place of Burial ...... inthron inthrop, lass.
Cemetery.
This copy of Certificate received for record at
this .............................
day of. 19
Registrar.
.
STATES
mich.
1,1919
.
Burial permiti issued in Boston.
Body was ab northern District Mortuary,
04/28/19
..
RM R-303
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH (ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTER 24)
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
Suffolk.
State
Registered No.
St.,
Ward
(If death occurred in a hospital or in itution, give its NAME instead of street and number)
Francis Mallon
(If in the Armylor Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abodc)
Length of resideoce io city or towo where death occurred years
months
days
How loog io U. S., if of foreigo hirth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGES, MARRIED, WIDOWED OR
DIVORCED (writethe word)
single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
( Month)
(Day) (Year)
Months
Days
If LESS than
1 day, ...... hrs.
If STILLBORN, eoter that fact here
If STILLBORN, state period of oterogestatioo
mooths
or ....... mio.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kiod of work. Druggist
Cambridge mass
James mulloney
11 BIRTHPLACE OF FATHER (City) .. (State or country)
Boston mass.
13 BIRTHPLACE OF MOTHER (City) (State or country)
Martha Bresnahan Cornualis n. S.
15
May 7 1919
(Month) /(Day) ( Year)
REGISTRAR
Official position.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
March 1(?), 1919
(Month)
(Day)
17
I HEREBY CERTIFY that I have investigated the death of the person ahove-named and that the CAUSE AND MANNER thereof are as follows:
Drowning under cis- cunstances & unknown, presumably Suicidal
(See reverse side for description for unknown person)
18 Where was injury sustained if not at place of death? (Signed) George Burgen Magnets .. , M.D.
(Address)
Suforth
Date
Medical Examiner for.
akux 26
(Month)
(Daf)
1919
( Year)
19 PLACE OF BURIAL, CREMATION, or REMOVAL
Camb lem Came
(Cemetery)
(City or town)
20 UNDERTAKER
Timothy St Leaneby
DATE OF BURIAL April 29 (Month) (Day) (Year)
ADDRESS
21 Burial permit issued by ..
22 Date of issue
Permit No ..
MARGIN RESERVED FOR BINDING
2 FULL NAME 3 SEX 6 DATE OF BIRTH 7 AGE 35 Years (b) General nature of iodustry, business, or establisbmeot in which employed ( or employer) (c) Name of employer 10 NAME OF FATHER 12 MAIDEN NAME OF MOTHER PARENTS 14 Informant ... (Address) Fil should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, for extracts from the laws relative to the return of certificates of death. so that it may be properly classified under the International Classification of Causes of Death. See reverse side N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information 9 BIRTHPLACE (City) (State or country)
10,4 89
City or Town ..
Harbor- Journal at
38 Charmword St.,
( If non-resident give city or town and State)
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician 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 stand- ard 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 so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
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 city or town in which the person died; . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . a satisfactory written state- ment containing the facts required by law to be re- turned and recorded, which . . . shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as herein- after 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, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . . . The person to whom the permit is so given and the physician who certifies to 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. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise
a descriptio, of such person, as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are sup- posed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
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 discase 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 supposably 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 in- jury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause, the nature of an injury and of its consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway accident." "Pistol shot wound of the chest with associated hemorrhage, homi- cidal." "Asphyxiation by suspension, suicidal." "Syn- cope while under the influence of ether administered as a surgical anæsthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If investigation shows the death to have been due to dis- ease, specify: (1) Under cause, its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous, of the brain (basal gangloid) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS : No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have come to his death by violence, until a permit in writing, signed by the Medical Examiner, has first been obtained. - Revised Laws, Chap. 24, Sec. 20.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
Found apr. 25
Ich. 1(!) 1919
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State
Massachusetts
Registered No ..
....... ......... .... or
City.
BOSTON
No.
14 Waldemar Ave ..
St., .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Julia LWolcott.
(If in the Army or Nay ofthe yarddemar ""Afganization, etc.)
Ward.
(If non-resident give city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) March 2
1919
17
I HEREBY CERTIFY, That I attended deceased from
Novembre /20
1918
marche 2
to.
1919
that I last saw
alive on
March 1st
1919.
and that death occurred, on the date stated above, at
7- 45 a m. The CAUSE OF DEATH* was as follows :
(duration)
about 5
yrs ..
.mos .............
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs ................. mos .............
.ds.
18 Where was disease contracted
if not at place of death ?
FOR WHAT?
Did an operation precede death? Uto Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed)
Velson y Wood
M.D.
3/1,1919 (Address) 72 High St Charlesto
* State the DISEASE CAUSING DEATHI, or in deaths from VIOLER?Cred state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
Informant
mire- Wild
(Address)
14 Valdemar Que .
Fil Mar 19. 2019
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Winthrop Cem.
DATE OF BURIAL march of 1919
20 UNDERTAKER
MS Vatersyandan
·
ADDRESS
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