Town of Winthrop : Record of Deaths 1919-1921, Part 46

Author: Winthrop (Mass.)
Publication date: 1919
Publisher:
Number of Pages: 1192


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 46


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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30 1884


St.,


.Ward.


(If non-resident give city or town and State)


County


Su folk


EXTRACTS


tetanus.


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 discase of which he died [defined so that it can be classified under the international classification of eauses 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. S22.


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 eity 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 containing the facts required by law to be returned 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 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 certificata as is required of the attending physician. If death is caused by vio- lence, the medical examiner only shall make such certificate. . . . The person to whom the permit is so given and the physician who certifics to the cause of death shall thereafter furnish for registration any other necessary infor- mation which can be obtained as to the deceased, or as to the manner or cause of the death, which the elerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.


Medical examiners shall, in all eases, certify to the eity or town clerk or to the eity registrar in the place where the deceased 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 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 ealls 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 eertify 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 attendanee 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 (ineluding 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.


STATEMENT OF CAUSE OF DEATH


For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably sueh, 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) should also be stated.


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


The Commonwealth of Massachusetts


CERTIFICATE OF DEATH OF NON-RESIDENT


BOSTON ...................


( City or town) 80 70


1 PLACE OF DEATH


Registered No


(Place of death)


Registered No.


(Place of residence)


City or Town


Boston


No.


MASS.CHAR.E.& E.INF.


St.,


Ward


(If death occurred in a hospital or institution, give its NAME instead of street and number)


2 FULL NAME


JOHN ATLAS


MASS.


City or Town


WINTHROP


No.


26 WAVEWAY AVE.


St.


(a) Residence. State.


(Usual place of abode)


Length of residence in city or town wbere death occurred


years


months


days


How loog io U. S., if of foreign birth?


years


months days


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


M


4 COLOR OR RACE


W


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


SIN.


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


6 DATE OF BIRTH (month, day, and ycar) 1906


7 AGE


12


Years


Months


Days


If LESS thao


1 day, ........ hrs.


or ........ min.


If STILLBORN, enter that fact bere


8 OCCUPATION OF DECEASED (a) Trade, profession, or particolar kind of work


(b) General nature of industry,


business, or establishment in


which employed (or employer )


(c) Name of employer


9 BIRTHPLACE (clty or town) BOSTON


(State or country)


CONTRIBUTORY


(SECONDARY)


(duration)


....... yrs.


mos.


3


ds.


10 NAME OF FATHER


BARNET ATLAS


18 Where was disease contracted


if not at place of death ?


Did an operation precede death ?.


YES


Date of


AUG .20


Was there an autopsy?


What test confirmed diagnosis?


(Sigoed)


H.M .FROST


M.D.


, 1919 (Address)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


WOBURN(BETH JOSEPH)


DATE OF BURIAL


AUG . 249 19


15 AUG.25.


Filed


1919


Registrar of city or towo where death occorsed


Filed.


Sept. 9


19 19 Eulalie Churchill


Des Registrar of city or town where deceased resided


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


of certificate.


PARENTS


11 BIRTHPLACE OF FATHER (city or town)


(State or country)


RUSSIA


12 MAIDEN NAME OF MOTHER JENNIE ATLAS


13 BIRTHPLACE OF MOTHER (city or town)


(State or country)


RUSSIA


14 FATHER


Informant


(Address)


(duration) ..


2


yrs.


mos


.ds.


· 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.) RT.& LT.OTITIS MEDIA WITH RT.MAS-


TOIDITIS -- OPR.DRAINAGE RT.MASTOID LIGATION RT. JUGULAR VEIN


16 DATE OF DEATH (month, day, and year)


AUG.22


1919


17


I HEREBY CERTIFY, That I attended deceased from


AUG 18


19.19 ...... ,


to


AUG.22


19.19 ..


..... ,


that I last saw h ...


1.M. alive on.


AUG.22


19.19 ..


and that death occurred, on the date stated above, at


2.30P


m.


The CAUSE OF DEATH* was as follows :


STREPTOCOCCUS MENINGITIS


AUG. 18


20 UNDERTAKER


MANUEL STANETSKY


ADDRESS


BOSTON


County


Suffolk


State


Massachusetts


.........


(If in the Army or Navy of the United States, give rank, organization, etc.)


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 inay form part of the second statement. Never return "Laborer," "Forcinan," "Manager," "Dealer," etc., without inore precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Wonen at hioine, 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 cinployed, as At school or At home. Care should be taken to report spe- cifically thic 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 DEATII, state occupation at beginning of illness. If retired from business, that fact may be iudi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of causo of death .- Nainc, first, tlic DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted tern 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- tous 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- Inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- P'ERAL 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 (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.)


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 Examincrs:


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 due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


ADDITIONAL SPACE FOR FURTHER STATEMENTS


PIIYSICIAN.


BY


R& 303. 6-'18. 50.000.


-


R-301


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


1 PLACE OF DEATHY LLOR County.


State


Registered No.


City or Town


No ..


St.


Ward


If death occurred In a hospital or institution, give its NAME instead of street and number)


2 FULL NAME


(If in the Army or Navy of the United States, give rank, organization, etc.)


(a) Residence. No.


(Usual place of abode)


55 Sumany


Se le 50,25 Ward.


(If non-resident give city or town and State)


Length of residence in any er town where death occurred


X


years


3


months


days.


How long in U. S., if of foreign birth ?


years


mooths days


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


of late


5a Hf murwied, widowed, or divorced


HUSBAND f


(or) WIFE of


Daniel. E. Saumon


6 DATE OF BIRTH


( Month)


.... (Year) 12 - 1833 (Day)


7 AGE


Months


Days


If LESS than 1 day, hrs.


8 OCCUPATION OF DECEASED (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


9 BIRTHPLACE (City ) (State or country)


10 NAME OF


FATHER


PARENTS


11 BIRTHPLACE OF FATHER (City). (State or country)


theblack


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (City) (State or country)


thatlejte


14


Informant Mrs . I. E. Emmons


(Address)


55 Quay Side are


15


Filed au9, 30 1919 Eulalie Churchill


(Months (Day) (Year)


ais REGISTRAR


21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued ... .1. pour


Official position. É'salte Eljuez?


: Date of issue of burial or transit permit


DATE OF BURIAL amy 27 1919


20 UNDERTAKER


ADDRESS


100,000.


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


aug. (Montły)


(Day)


1919. (Year)


17


I HEREBY CERTIFY, That I attended deceased from


aug, 18.


19/9, to


24, 1919.


that Hast saw her alive on augte 23.


and that death occurred, on the date stated above, at . .. m. The CAUSE OF DEATH was as follows :


or min. arteriosclerosis.


Indef.


CONTRIBUTORY ( SECONDARY)


(duration)


yrs


mos.


ds.


18 Where was disease contracted


if not at place of death ?


Did an operation precede death ?


Date of


-


Was there an autopsy ?


no.


clinical


What test confirmed diagnosis ?


If Parte


(Signed)


, M.D.


( Address ).


Winthrop, Mexa.


Date


augs ret.


( Month)


(Day)


yrs.


moş .. .


ds.


(duration) Catarrhat Handec.


Shopleigh


mos.


&5 Years


If STILLBORN, enter that fact here


If STILLBORN, state period of uterogestation


nov


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


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


Jacol me Laurel Hace


(Cemetery)


(City or town)


REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH


[Approved 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, 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 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 arc 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, etc. If the occupation has been changed or given up on account of the DISEASE CAUSINO 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 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," unqualified, is 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 be 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," ete.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., 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 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 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 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 thereof 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 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 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 disabled by recognized diseasc 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 clectrical 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.


R-301


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


1 PLACE OF DEATH Ludfolk


County.


.


... State .. Man


Registered No.


St ..


Ward


(If death occurred in a hospital or institution, give its NAME instead of strect and number)


2 FULL NAME


Lester Hamilton Belchen


(If in the Army or Navy of the United States, give rank, organization, etc.)


(a) Residence. No.


(Usual place of abode)


119 Harmon


St.,


Ward.


(If non-resident give city or town and State)


Leogth of residence in city or town where death occorred 26 years 5 months " days . How loog in U. S., if of fereigo hirth ? years


months days


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


While


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


mascul


5a If married, widowed, or divorced HUSBAND of fort WIFE of Florence. M. Belcha


6 DATE OF BIRTH


mas ( Month)


(bay)


(Year)


7 AGE 2C Ycars 5 Months " Days


If STILLBORN, eoter that fact here If STILLBORN, state period of uterogestatioo mos.


or


min.


8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kiod of work. (b) Geoeral oature of industry, business, or establishment io which employed (or employer)


Brada 8 Kyun R.R


9 BIRTHPLACE (City ) (State or country) mars


10 NAME OF


FATHER


warm - 1.


11 BIRTHPLACE OF


FATHER (City)


(State or country) Mars


12 MAIDEN NAME


OF MOTHER


Ella Pension


13 BIRTHPLACE OF MOTHER (City) (State or country)


14 Wife thoresen M. Belchen


Informant (Address) 119 Human dla


15 Filed aug.20. 1919 Eulalie Churchill


(Monthy (Day) (Year) 1 asal REGISTRAR


21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the borial or transit permit was issued-


1


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH august


(Month)


24


Way)


19 19


Year)


17


I HEREBY CERTIFY, That I attended deceased from


Jul


J


,19 19


aug 24


,19./7,


to.


alive on august 24, 1919, and that death occurred, on the date stated above, at


2 P m. The CAUSE OF DEATH was as follows : Chemie Endocarditis Chemin interstitial ntploitis


(duration)


yrs ...


5


mos.


ds.


CONTRIBUTORY. ( SECONDARY)


(duration)


yrs ....


.mos.


ds.


18 Where was disease contracted


if not at place of death ?


Did an operation precede death?


no


Date of.


Was there an autopsy ?


no


What test confirmed diagnosis ?


Personal examinations


(Signed)


, M.D.


( Address ).


man.


Date


august


Month)


(Day)


25


1919.


,


(Year)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL




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