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