USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1928-1930 > Part 27
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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, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, 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 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, 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, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Boston
1 PLACE OF DEATH
County
Suffolk
State
Registered No.
(Place of residence)
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
IDA COHEN
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
State
MASS.
City or Town
WINTHROP
No.
44 UNDERHILL
St.
(Usual place of abode)
Length of residence in city or town where death occurred
years months
days.
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
W.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
W
5a If married, widowed, or divorced
S HUSBAND
Name of ? (or) WIFE
MAYER
6 AGE
Years
67
Months 10
Days
14
If LESS than 1 day, .... hrs. or .... min. -
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (b) Name of employer
HOUSEWIFE
8 BIRTHPLACE (city or town)
(State or country)
POLAND
9 NAME OF
FATHER
LEOPOLD
10 BIRTHPLACE OF FATHER (city or town) (State or country) POLAND
11 MAIDEN NAME
OF MOTHER
ETHEL GORDON
12 BIRTHPLACE OF MOTHER (city or town) (State or country) POLAND
13
Informant
NATHANIEL COHEN
(Address)
153 RICHMOND ST.
14
Filed
APR. 27 28
Filed
May 2, 19 28
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
1928
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
That I attended deceased from
27 to
APRIL 22
19 28
MAR. 4
19
that I last saw h ER alive on APRIL 22 ., 19_28
and that death occurred, on the date stated above, at
9,40 P
The CAUSE OF DEATH was as follows: (State fully)
HYPERTROPHIC ARTHRITIS -- PLEURISY- EFFUSION.
(duration).
yrs.
X
mos.
.ds.
CONTRIBUTORY
ACUTE DILATATION OF HEART
(SECONDARY)
(duration)
yrs.
mos.
1
da.
17 Where was disease contracted if not at place of death.
Did an operation precede death For what.
Date of operation
Was there an autopsy
What test confirmed diagnosis
(Signed)
NATHANIEL M. COHEN
, M. D.
(Address)
Date APRIL 24, 1928
18 PLACE OF BURIAL, CREMATION, OR REMOVAL (BETH ISRAEL) W. ROX (Cemetery) (City or town)
DATE OF BURIAL
4-26
, 19 28
19 UNDERTAKER
I. EINSTEIN
ADDRESS
may be properly classified. Exact statement of OCCUPATION is very important. PARENTS
. 4312
City or town)
Registered No.
4003
( Place of death),;
Boston
-No.
250 SEAVER
City or town
F.
15 DATE OF DEATH
APRIL 24
apr. 24. 1928
-
:
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Boston
1 PLACE OF DEATH
County
Suffolk
State
Registered No.
(Place of residence)
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
ELIZABETH WELSH
(If in the Army or Navy of the United States, give rank, organization, etc.)
City or Town
WINTHROP
No.
37 SIREN
St.
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
F .
4 COLOR OR RACE
W.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5
58 If married, widowed, or divorced § HUSBAND Name of ? (or) WIFE
6 AGE
Years
Months
Days
23
If LESS than 1 day, .... hrs. or .... min.
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (b) Name of employer
8 BIRTHPLACE (city or town)
WINTHROP
(State or country)
MASS.
9 NAME OF
FATHER
HARRY
10 BIRTHPLACE OF
FATHER (city or town)
(State or country) SCOTLAND
11 MAIDEN NAME
OF MOTHER
MARGARET MC ASLEN
12 BIRTHPLACE OF
MOTHER (city or town)
(State or country)
SCOTLAND
13 Informant
FATHER
(Address)
37 SIREN ST. WINTHROP
14
Filed
MAY 1 , 19 28
EMM Ilenen
Registrar of city or town where death occurred
Filed
22. 7. 19 28
Registrar of city or town where deceased resided
. 4312
MEDICAL CERTIFICATE OF DEATH
1928
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
APRIL 25
19
28
to
APRIL 27
19 28
that I last saw h.
ER
alive on
APRIL 27
19
28
and that death occurred, on the date stated above, at.
7 P
The CAUSE OF DEATH was as follows: (State fully)
STREPTOCOCCUS MENINGITIS
(duration)
yrs.
mos
5
CONTRIBUTORY
STRPTOCOCCUS SEPTICEMIA
(SECONDARY)
(duration)
утв.
mos
4 ds.
17 Where was disease contracted
if not at place of death
Did an operation precede death. For what
Date of operation
Was there an autopsy
What test confirmed diagnosis
(Signed)
H. E GALLUP
M. D.
(Address)
Date APRIL 28, 1928
18 PLACE OF BURIAL, CREMATION, OR REMOVAL (WINTHROP CEM. ) WINTHROP (Cemetery)
(City or town)
DATE OF BURIAL
4-29
, 19 28
19 UNDERTAKER R. C. KIRBY
ADDRESS
may be properly classified. Exact statement of OCCUPATION is very important. PARENTS
City or town)
Registered No.
4135
(Place of depth)
City or town
Boston
No.
INFANTS HOSPITAL
(a) Residence.
State
(Usual place of abode)
MASS.
15 DATE OF DEATH
APRIL 27
That I attended deceased fro
apr. 27.1928
2
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County.
Hampden
State
Mass.
Registered No.
(Place of residence!
.St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
James JustinGallagher
(If in the Army or Navy of the United States, give rank, organization, etc.)
City or Town
winthrop
No.
11 George
.St.
(Usual place of abode)
2
5
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
ingle
5a If married, widowed, or divorced
Name of
S HUSBAND
(or) WIFE
6 AGE
Years
3
Months 5
Days
3
If LESS than 1 day, . . . . hrs. or .... min.
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
none
(b) Name of employer
8 BIRTHPLACE (city or town)
Winthrop
(State or country)
Mass.
9 NAME OF
FATHER
James Henry Gallagher
10 BIRTHPLACE OF
FATHER (city or town)
Charlestown
(State or country)
Mass .
1 MAIDEN NAM
OF MOTHER
Catherine I. Steerin
12 BIRTHPLACE OF
MOTHER (city or town)
F. Boston
(State or country)
Mass .
13
Informant
Records Monson State Hospital
(Address)
+ c. Palmer Mass .
14
Filed
Arr. 30, 1926
Filed
,19
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
April 27, 1928
15 DATE OF DEATH
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY, That I attended deceased from
Feb.
128, to Apr. 26,
1928.
that I last saw h
im
alive on
Apr. 26,
28
19
9.45 a.
and that death occurred, on the date stated above, as
m.
The CAUSE OF DEATH was as follows: (State fully)
Epilepsy
2
1]
(duration)
yrs.
mos.
de.
Gastro enteritis
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
mos. 7
.ds.
17 Where was disease contracted
if not at place of death.
uninwon
Did an operation precede death
no
_For what.
Date of operation
no
Was there an autopsy
clinical findings
What test confirmed diagnosis.
amel
Miller
(Signed)
M. D.
(Address)
P.n. Palmer, Maas.
Date
April º, 192º
18 PLACE OF BURIAL, CREMATION, QR REMOVAL
Holy Cross Malden
Arr . 30
DATE OF BURIAL
, 19
(Cemetery)
(City or town)
19 UNDERTAKER T. T. Velly & Con
ADDRESS
448 rambridge
Ft .
F. Cambridge
may be properly classified. Exact statement of OCCUPATION is very important. PARENTS
0. 4312
Registrar of city or town where death occurred
Registered No.
( Place of death)
City or town
Morson
No. Monson State Hospital
(a) Residence.
State
Ma83.
-
James Justin Gallagher april 27.1928
R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS 1 PLACE OF DEATH County Suffolk
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Lass
(City of town) Registered No.
81
City or Town Winthrop
No.
St. Ward (If death occurred in a hospital or institution, give its NAME instead of street and number)
12FULL NAME
Richard J. Perry
(If U. S. War Veteran, specify WAR)
K(a) Residence. No
235 Washington Ave.
St.
Ward
(If non-resident give city or town and state)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth?
years
months
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Male
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5ª If married, widowed or divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
Months
Day:
IF LESS than
1 day, ........ hrs.
c ......... min.
28
IF STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
8 BIRTHPLACE (City)
Chelsea
(State or country)
Mass
PARENTS
9 NAME OF
FATHER
Phillip
10 BIRTHPLACE OF
FATHER (City)
So. Boston
(State or country)
Mass
1 1 MAIDEN NAME
OF MOTHER
Eleanor V. Tobin
12 BIRTHPLACE OF
MOTHER (City)
St. John
(State or country)
N.B.
13
Informant Phillip Perry
(Address)
235 Washington Ave/
14 Filed (Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
April
(Month)
(Day>
(Year)
16
I HEREBY CERTIFY , That I attended deceased from
2 A.M. April 28.
1928, to 3 P.M. April 28-
1928.
that I last saw hirn alive on
April
19
3
m.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows: (State fully)
Branduol Presenças
(duration)
yrs.
_mos
2
ds.
CONTRIBUTORY
(Secondary)
(duration).
_yrs.
mos ds.
Did an operation precede death
20
For what
Date of operation
Was there an autopsy no
What test confirmed diagnosis Edward . Franges (Signed)
none ?
, M. D.
(Address)
7 Imain Street
Date
April 28. 4929
18 PLACE OF BURIAL, CREMATION, OR REMOVAL Holy Cross Malden (Cemetery) (City or town)
DATE OF BURIAL 4/30/28
ADDRESS 1 9 UNDERTAKER John F O'malley Hinterch
20 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Im. X. Childress
Fil Healthe Office
Date of Issue 4/3/6/28 Permit No. 14/06
200.000. 9-26. NO. 6373
Exact statement of OCCUPATION is very important. See instructions and extracts from the laws on back of certificate. plied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified-
State
235 Washington Ave.
(Usual place of abode)
28
1928
1 7 Where was disease contracted
if not at place of death
REVISED UNITEDSTATESSTANDARD 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 Planter, 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 Duy 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 DISEASE CAUSING DEATH, state occupa- tion 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. 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 discase; 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 symp- tomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases 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, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin- gitis, miscarriage, necrosis, peritonitis, phlebitis, premia, 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 or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, or from one cemetery to another, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certi- ficate 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 ob- tained early enough for the purpose, 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, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If the death certi- ficate contains a recital, as required by section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health or its agent, upon receipt of such statement and certificate, shall forthwith counter- sign it and transmit it to the clerk of the town for registration. 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 require .- Chap. 114, Sec. 45, G. L., as amended.
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.
No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made .- Chap. 114, Sec. 46, G. L., as amended.
-303
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
Medical Examiner's Certificate of Death (ISSUED UNDER THE PROVISIONS OF GENERAL LAWS, CHAPTER 38)
(City or town)
1 PLACE OF DEATH
County
Suffich-
City or Town.
Withings.
Frederick marshall
2 FULL NAME
Wanthop
State Corato Stu. BRBLLRR-
Registered No.
82
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(a) Residence. No. Wenthing: 33 chest and St.
Ward.
(Usual place of abode)
Length of residence In city or town where death occurred
years
months
days
How long In U. S., If of toreign birth?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male White
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR BIVORCED (write the word) Married
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
Curabeth B. Marshall
Years
Months
Days
If less than 1 day, ..... hrs. or ...... min.
IF STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Conductor
Bostan R. B. T.J. R.R.
8 BIRTHPLACE (City)
(State or country)
nova scotia
Burton Varahale
Maria Jene
11 MAIDEN NAME OF MOTHER
12 BIRTHPLACE OF MOTHER (City) (State or country) Nova Scotia
Informant
Elisabeth Marshall
(Address) 2 heater wewaittrois
Filed
(Month)
(Day) (Year)
REGISTRAR
20 Burial permie issued by
Www. D. Childress
Official
Healthe Officer
21 Date of
issue ..
4/30/28
Permit No. 1405
, M.D.
(Address)
Bale
Medical Examiner for.
arme 28th
1922
(Month)
(Day)
(Year)
18 PLACE OF BURIAL, CREMATION, or REMOVAL
Winthrop
Win throp
(Cemetery}
(City or town)
19 UNDERTAKER Jong& Margeson
DATE OF BURIAL / 1 1/1928 (Month) (Day) (Year) ADDRESS wintegrato
9 NAME OF FATHER PARENTS 13 14 Death. See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes of information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF (b) Name of employer
15 DATE OF DEATH
april
( Month)
28 (Day)
1928
(Year)
16 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: Natet Cames :-
Cardiovascular disease-
(See reverse side for description for unknown person)
17 Where was injury sustained
if not at place of death ?
(Signed)
10 BIRTHPLACE OF FATHER (City) (State or country) Nova scotia!
annapolis country
6 AGE 65 0
6
16,400
Af in the Army or Navy of the United States, give rank, organization, etc.)
(If non-resident, give city or town and state)
EXTRACTS
FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has at- tended during his last illness, at the request of an under- taker 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 clas- sified under the international classification of causes of death), 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. . . .- General Laws, Chapter 46, Section 9.
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