Town of Winthrop : Record of Deaths 1922-1924, Part 186

Author: Winthrop (Mass.)
Publication date: 1922
Publisher:
Number of Pages: 1202


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1922-1924 > Part 186


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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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. Exam- ples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneu- monia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, meninges, 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 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 conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convul- sions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Ex- haustion," "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 childbirth or miscarriage, as "PUERPERAL 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 "primary"; 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, ceiiuiitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipeias, meningitis, miscarriage, necrosis, peritonitis, phiebitis, 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 forth- with, 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 registra- tion a standard certificate of death, stating to the best of his knowl- edge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required 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 shali be issued untii there shaii 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, in case of an original interment, 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 pur- pose, or is insufficient, a physician who is a member of the board of heaith, or employed by it or by the selectmen for the purpose, shali upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shail make such certificate. . . The person to whom the permit is so given and the physician 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 re- quire .- 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; otherwise 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 unre- lated to any form of injury, have died without recent medical at- tendance 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 injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


ORM R-301


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


Wartent


(City or towb)


State


Registered No.


War


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


James William Davis


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


St.


Ward.


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


days.


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


years


months days


MEDICAL CERTIFICATE OF DEATH


15 DATE OF DEATH


(Month)


July


3 1924


(Day)


(Year)


16


I HEREBY CERTIFY, That I attended deceased from


1922, to


July 3


1924


July 3


, 19 24


and that death occurred, on the date stated above, at /2 hoorn The CAUSE OF DEATH was as follows: Hemiplegia (Left)


Cerebral I Romanhage


(duration)


=yrs .___ mos.


ds.


/2


CONTRIBUTORY


arteriosclerario


17 Where was disease contracted


if not at place of death?


Did an operation precede death?


200


Date of


Was there an autopsy?


200


What test confirmed diagnosis?


clinical


(Signed)


(Address)


123


Date


July - 4 -1924 Unictus


(Month)


(Day)


(Year)


18 PLACE OF BURIAL, CREMATION OR REMOVAL


oak Grove


(Cemetery)


(City or town)


19 UNDERTAKER


OR Bonnesai


ADDRESS


winchof-


20 | HEREBY CERTIFY thet a satisfactory stan- dard certificate of death was filed with me BEFORE the burial os transit permit was issued J.O. Daniela


Official position, Heath lider


Date of issue of permit 7/5/24


Permit NO. 760


MARCIN RESERVED FOR DINDING


PLACE OF DEATH Surfakt


County


Nachot


City or Town


No.


2 FULL NAME


70 Bowdown


(a) Residence. No.


(Usual place of abode)


Length of residence in city or town where death occurred


42


years


months


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


white


Mall


5a If married, widowed or divorced


HUSBAND of


(or) WIFE of


6 AGE


Years


Months


8


Days


7


20


If STILLBORN, enter that fact høre


7 OCCUPATION OF DECEASED


(a) Trade, profession, of


particular kind of work


Engemann


8 BIRTHPLACE (City)


(State or country)


medford


mass


9 NAME OF


FATHER


James Davis


10 BIRTHPLACE OF


FATHER (City)


F Unable to obtain


(State or country)


PARENTS


Informant


should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH


14


7-9-24


Filed


(Month)


(Day) (Year)


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


(b) Name of employer


BRBQL. R.R. BAR


11 MAIDEN NAME


OF MOTHER


Elyahut : Unknown!


12 BIRTHPLACE OF Unable to obtain MOTHER (City) (State or country)


13 Bessie. M. Glover (Daughter)


(Address)


70 Bodedou St Wintherdi man


REGISTRAR


-'23-100.000


5 SINGLE, MARRIED, WIOOWEO, OR


DIVORCEO (write the word)


Willower


Many Edwards . desene (


that I last saw h am alive on


If LESS than


1 day .___ hrs.


or __ min.


(duration)


yrs __ mosds


DATE OF BURIAL July 5/24


0


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, irre- spective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Pianter, Physician, Com- positor, Architect, Locomotive engineer, Civil engineer, Stationary fire- man, 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," "Fore- man," "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 House- wife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report specifically 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 nisEASE CAUSING DEATH, state occupa- tion at beginning of illness. If retired from husiness, 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. Exam- ples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneu- monia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, meninges, 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 intercurrent) affection need not be stated unless important. Example: Measles (disease causing death), 29 de .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convul- sions," "Dehility" ("Congenital," "Senile," etc.), "Dropsy," "Ex- haustion," "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 childbirth or miscarriage, as "PUERPERAL septicemia," "PUERPERAL peritonitis," etc.


State cause for which surgicai 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 "primary"; if secondary, give primary cause.


Certificates wili be returned for additional information which give any of the following diseases, without explanation, as the soie cause of death: Abortion, celluiitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipeias, meningitis, miscarriage, necrosis, peritonitis, phiebitis, 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 forth- with, 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 registra- tion a standard certificate of death, stating to the hest of his knowl- edge and helief the name of the deceased, his supposed age, the disease of which he died, defined as required 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 hoard of health or its agent. . . or ... from the clerk of the town where the person died ;. . . No such permit shail 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 he accompanied, in case of an original interment, 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 pur- pose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shail upon application make the certificate required of the attending physician. If death is caused by violence, the medicai examiner shali make such certificate. .. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can he obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may re- quire .- Gen. Laws, Chap. 114, Sec. 45.


Medicai examiners shall make examination upon the view of the dead hodies of only such persons as are supposed to have died hy 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; otherwise a description as full as may he, 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 Heaith Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unre- lated to any form of injury, have died without recent medical at- tendance 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 ahortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabied by recognized disease, and those of persons found dead.


STANDARD CERTIFICATE OF DEATH


DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS


Registered No.


or


Village


or


No. Station Hospital Fort Banks Mass St.


Ward


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


2 FULL NAME


John


Dwyer Hubbard


(a) Residence. No. .


Fort Strong, Mass


St.


Ward.


(Usual place of abode)


Length of residence in city or town where death occurred


yrs.


mos.


ds.


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


yrs.


mos.


ds.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH (month, day, and year) July 4,


19 24


17


I HEREBY CERTIFY, That I attended deceased from


July __ 4


19 __ 24, to


July .. 4


19.24-,


that I last saw h-


im


alive on


4


19


24


and that death occurred, on the date stated above, at 8: 30 F.m.


The CAUSE OF DEATH* was as follows:


Gastric hemorrhage,sever


Pulmonary oedema


(duration)


yrs.


mos.


ds.


CONTRIBUTORY


reaction following typhoid


ifftentation


(duration)


yrs.


18 Where was disease contracted


mos.


ds.


if not at place of death ?


Fort __ Strong, Mass


Did an operation precede death ?


No


Date of


Was there an autopsy?


Yes


What test confirmed diagnosis? rathological findings


Ruhunurel,


Major, M. C


M. D.


(Signed>


12 MAIDEN NAME OF MOTHER


Nellie Josephine De 19 2 (Address)


Fort Banks, 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.)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


DATE OF BURIAL


192


20 UNDERTAKER


ADDRESS


Filed 7/9/ 1924


REGISTRAR


11 -- 3184


1 PLACE OF DEATH


County


Suffolk


Township


Winthrop


City


3 SEX


4 COLOR OR RACE


W


Male


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


7 AGE


Years


Months


Days


17


7


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


particular kind of work ...


Soldier


(b) General nature of Industry,


business, or establishment In


9 BIRTHPLACE (city or town)


Guildhall


(State or country)


Vermont


PARENTS


13 BIRTHPLACE OF MOTHER (city or town)


(State or country)


Ireland


14


Informant-


Ernest A. Hubbard


mation should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state


(c) Name of employer


15


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 plain terms, so that it may be properly classified. Exact statement of OCCUPA-


which employed (or employer)


U. S. Army


5 SINGLE, MARRIED, WIDOWED.


OR DIVORCED (write the word)


Single


6 DATE OF BIRTH (month, day, and year) Nov. 8, 1906


26


If LESS than


1 day, ---- hrs.


or ---- min.


10 NAME OF FATHER


Ernest A. Hubbard


11 BIRTHPLACE OF FATHER (city or town)


Guildhall


(State or country)


Vermont


(Address)


6. Court St., Boston, Mass.


H. C. Daniele Watch 7, 2/24


7/22


MARGIN RESERVED FOR BINDING


·8-209 ₫ V. S. No. 98


State


MASSACHUSETTS.


(If nonresident give city or town and State)


0


11


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. 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," 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 disease; 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"? (merely symptom-


atic), "Atrophy,", "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy,"? "Exhaustion,"' "Heart failure," "Hemorrhage,"3 "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 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 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.


But notifie


STANDARD CERTIFICATE OF DEATH


DEPARTMENT OF COMMERCE BUREAU OF THE CENSU8


1 PLACE OF DEATH


County


Suffolk


State


MASSACHUSETTS.


Registered No.


Township


Winthrop


or Village


or


No. Station Hospital Fort Banka Mass .... St., ..


Ward


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


2 FULL NAME


Margaret ruth McCormack


(Stillton)


(a) Residence.


No.


4% Waverly St. Roxbury, Mass St,


Ward.


(If nonresident give city or town and State)


Length of residenco In city or town where death occurred


yrs.


mos.


ds.


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


yrs.


mos,


ds.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


1924


3 SEX


Fema la


4 COLOR OR RACE


White


5 SINGLE, MARRIED, WIDOWED,


OR DIVORCED (write the word)


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


6 DATE OF BIRTH (month, day, and year) June 5, 1924.


7 AGE


Years


X


Months


-


Days


If LESS than 1 day,_O_ hrs. or _O_ min.


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


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


What test confirmed diagnosis ?


(Signed)


Tuy W Layton


M. D.


7/6,192(Address) Station Hospital, Fort Banks, Mas


* 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.)




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