USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 184
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What test confirmed diagnosis?
(Signed)
I .. ". Browne
M.D.
, 19
(Address)
hur.13
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Malden (Holy Cross)
DATE OF BURIAL
Aug. 16
1921
20 UNDERTAKER
C. H.Faunce
ADDRESS
Chelsea
of certificate.
13-'19. 25,000
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.
Allan F. Cameron
(If in the Army or Navy of the United States, give rank, organization, etc.)
im
Norman Cameron
PARENTS
1 01
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 inany 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," etc., without more precise specification, as Day laborer, Farm laborcr, 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 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," 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," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Urcmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. 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 atalaj
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.
.
STANDARD CERTIFICATE OF DEATH
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
1 PLACE OF DEATH
County
Suffolk
State
MASSACHUSETTS.
Registered No.
Township
or
Village
or
City
Winthrop
No.
Station Hospital, Fort Banks
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
IRENE LOULSE MAYNARD
(a) Residence. No.
Fort Standish, Mass.
St.,
Ward.
(If nonresident give city or town and State)
mos.
ds.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
August 12
1921
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE, MARRIED. WIDOWED,
OR DIVORCED (write the word)
Single
(Child)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
October 29, 1917
7 AGE
Years
Months
Days
3
9
13
8 OCCUPATION OF DECEASED
Child
(a) Trade, profession, or
particular kind of work -.
(b) General nature of Industry,
business, or establishment In
which employed (or employer)
(c) Name of employer
CONTRIBUTORY
(SECONDARY)
18 Where was disease contracted
(duration)
------ yrs. ....
· mos. ------ ds.
if not at place of death ?
Fort Standish, Mass.
Did an operation precede death ?
Date of
Was there an autopsy?
What test confirmed diagnosis ? (Signed)- Crest m. moms
,19 (Address)
Ernest M. Morris, Captain, M.C. Fort Banks, Winthrop, Mass.
* 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.)
14
Informant-
Millard Maynard (Father)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Winthrop cemetery
DATE OF BURIAL
any 13
1921
(Address)
Fort Standish, Mass
15
Filed
11-3184
REGISTRAR
20 UNDERTAKER
C. R. Bennison
ADDRESS
Winthrop
UV
-
-
17
I HEREBY CERTIFY, That I attended deceased from
July 24
21
to
August 12
19
21
19
that I last saw hex
alive on
August 11
19.
21
and that death occurred, on the date stated above, at.
1:05 Am.
The CAUSE OF DEATH * was as follows:
If LESS than 1 day, ---- hrs. or ---- min. Encephalitis lethargica
(duration)
- yrs.
mos.
21
ds.
9 BIRTHPLACE (city or town)
New York City
(State or country)
10 NAME OF FATHER
Millard Maynard
11 BIRTHPLACE OF FATHER (city or town)
Pikeville
(State or country) Pike County, Ky
12 MAIDEN NAME OF MOTHER
Aura Rantanen
13 BIRTHPLACE OF MOTHER (city or town)
Obo
(State or country)
Finland
PARENTS
V. S. No. 98
mation should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of Infor- TION is very important. See instructions on back of certificate. CAUSE OF DEATH In piain terms, so that it may be properly classified. Exact statement of OCCUPA-
(Usual place of abode)
Length of residence In city or town where death occurred
yrs.
mos.
20 ds.
How long In U. S., If of foreign birth ?
yrs.
.
Лед , 7, 19 71 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, 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," 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. Ifthe 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 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, peritoneum, etc., Car- cinoma, Sarcoma, etc., of .................. (name origin; “Can- cer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The con- 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 condi- tions, such as "Asthenia," " Anemia"? (mcrely symptom-
atic), "Atrophy,", "Collapse,", "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inani- tion," "Marasmus,"? "Old age,"" "Shock,"? "Uremia,"? "Weakness," etc., when a definite disease can be ascer- tained as the cause. Always qualify all diseases result- ing from childbirth or miscarriage, as "PUERPERAL septi- cemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHIS 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 cause 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 diseases, without explana- tion, as the sole cause of death: Abortion, cellulitis, childbirth, convul- sions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus." But general adoption of the minimum list suggested will work vast improve- ment, and its scope can be extended at a later date.
11-3184
ADDITIONAL SPACE FOR FURTHER STATEMENTS
BY PHYSICIAN.
.
M R-301
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
Se folk
City or Town
No.
State. Metcalf Hospital
St.,
.Ward
(If death occurred in a hospital or institution, give ius NAME instead of street and number)
2 FULL NAME
124 Kimball Ave Rever
Ward.
(If non-resident give clty or town and State)
months days
.PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
Aug
(Month)
10- ( Day)
1221 (Year)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
April 11-1891
(Day)
(Month)
( Year)
7 AGE
3 CAcars
Months
If STILLBORN, enter that fact bere
4
If STILLBORN, state period of nterogestation. ..
... ...
mos.
If LESS than 1 day, ..... brs. or ........ min.
Номенчре
8 OCCUPATION OF DECEASED2 (a) Trade, profession, or particular kind of work. (b) Generai nature of industry, business, or establishment in which employed ( or employer ) ... (c) Name of employer
9 BIRTHPLACE (City) ( State or country)
Boston.
10 NAME OF
FATHER
Timothy Shaughnessy
PARENTS
11 BIRTHPLACE OF FATHER (City). (State or country)
Berhlou
12 MAIDEN NAME OF MOTHER
Twenty
13 BIRTHPLACE OF MOTHER (City) (State or country)
Ireland
MMonth)
(Day)
(Year)
14
Informant (Address) 157 Balestre Kuvert
15 8/16/219
Filed (Month) (Day) ( Yenf)
REGISTRAR
21 I HEREBY CERTIFY that & etisfactory stan- dard certificate of death was hled with me BEFORE the burial or transit permit was issned
S.g. Mowry E.g.
Official position
Health Offre
22 Date of issue of burial or transit permit ...
aug. 12.21
17
I HEREBY CERTIFY, That I attended deceased from
auq 6 th
, 1924
, to.
aug. 12
, 19.2 1
that I last saw h ...
alive on
auqi2
4, 19
and that death occurred, on the date stated above, at The CAUSE OF DEATH was as follows : Mancho lu
mos ..
LI
ds.
CONTRIBUTORY
( SECONDARY)
(duration) .
yrs ....
mos ..
ds.
18 Where was disease contracted
if not at place of death ?
No
an operation precede dea
Date of
Was there an autopsy ?
What test confirmed diagnosis ? (Signed) Niaingu@liuTimes, M.D.
(Address ) ....
20
Date ..
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
(Cemeteryy (City or town)
20 UNDERTAKER
ADDRESS
Rever
8. 100,000.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, CR
DIVORCED (write the word)
harrold
{If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
Length of residence ia city or town wbere death occurred
years
months
Cevic north
Registered No.
Helen & Sullivan
days.
How long in U. S., if of foreign birth ?
years
3 SEX
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information 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
: m.
Days
Cina 1 2
197
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
1
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applics 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, Compasitor, Architect, Locamotive 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) Fareman, (b) Autamobile factory. The material worked on may form part of the second statement. Never return "Lahorcr," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Caal mine, etc. Women at home, who are engaged in the dutics of the house- hold only (not paid Housekeepers who receive a definite salary), may be entercd as Hausewife, Hausework, or At hame, and children, not gainfully employed, as At schaal or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Coak, Hausemaid, 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 (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Labar pneumonia; Bronchapneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinama, Sarcoma, etc., of .......... (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chranic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Branchapneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Dehility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases 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 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 belicf the name of the deceased, his supposed age, the discase of which he dicd [defined so that it can be classified under the international classification of causes of deatlı], 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 statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thercof a certifi- cate 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, 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 per- mit is so given and the physician who certifies to the cause of death shall thereafterfurnish 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 deccascd died, his name and residence, if known, otherwise a description 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 supposed 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 disahled 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 persons found dead.
M R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or Town)
State
Registered No.
City or Town.
No.
33 (Bay View Ave
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Catherine Caixeiro Brier
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
( Usual place of abode)
33 Bay View Avec St.
.. Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred
15 years
months
days.
How long in U. S., if of foreign birth ?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Antonio Brier
6 DATE OF BIRTH Unknown
(Month)
(Day)
( Year)
Years
Months
Days
If LESS than 1 day, ........ hrs. or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind ot work. At Home East Boston
9 BIRTHPLACE (City)
(State or country)
dass
10 NAME OF
FATHER
Thomas O'Brien
11 BIRTHPLACE OF FATHER (City ) .. (State or country)
Preland
12 MAIDEN NAME OF MOTHER HER Ann Carrigan
13 BIRTHPLACE OF MOTHER (City) (State or country)
Preland
14 Son Jour Brien
Informant ..
(Address)
33 Bay Ver Que
15
Filed (Month (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
( Month)
17 VHEREBY CERTIFY, That I attended deceased from 3/14 1921 TO.
Cung 16 , 19 21.
that I last saw h
( ....
alive on
aug 15
, 19 .... 1.
and that death occurred, on the date stated above, at
15 Pm.
The CAUSE OF DEATH was as follows :
.... mos .......... ..... ds.
Jen auteurs Sclerosis
CONTRIBU
(SECONDARY)
(duration)
.. yrs ....
mos.
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