USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1928-1930 > Part 55
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(If U. S. War Veteran, specify WAR)
Ka) Residence. No.
(Usual place of abode)
Days
PARENTS
Clinical Flatuatory
REVISED UNITEDSTATESSTANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and Arterican Public Health Association)
6
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 Day laborer, Farm laborer, Laborer-Coal mine, etc. Women at home, who are engaged in the duties of the household onty (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 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 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 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, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin- gitis, 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 of other person shall bury of 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 of 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 carly 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 oniy 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.
305
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
Medical Examiner's Certificate of Death
Boston (City or town)
1 PLACE OF DEATH
(ISSUED UNDER THE PROVISIONS OF GENERAL LAWS, CHAPTER 38)
County
Suffolk
State
Registered No.
No.
BOSTON CITY HOSPITAL
( Place of residence)
1
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(a) Residence. No.
1.19 OCEAN ST
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 toreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
M.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
MARY
6 AGE
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
LABORER
(b) Name of employer
8 BIRTHPLACE (city or town)
BOSTON
(State or country)
MASS.
9 NAME OF FATHER
HARRY
PARENTS
10 BIRTHPLACE OF FATHER (city or town)
(State or country)
IRELAND
11 MAIDEN NAME OF MOTHERMARY FITZPATRICK
12 BIRTHPLACE OF MOTHER (city or town)
(State or country)
IRELAND
13
Informant
ALICE G. CONLEY
(Address)
114 PLEASANT ST. BROOKLINE
Filed SEP 18 19 28 ENMYlenew Filed Sep. 25, 1928. Registrar of elty or town where death occurred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
SEPT 13, 1928
(Month)
(Day)
(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 :
ACUTE ... LOBAR .... P.NEUMONIA --
ALCOHOLISM
(See reverse side for additional space)
17 Where was injury sustained
if not at place of death ?
(Signed)
TIMOTHY LEARY
(Address)
BOSTON
Medical Examiner for SUE.FOLK
Dale
SEPT 13, 1928
(Month)
(Day)
(Year)
18 PLACE OF BURIAL, CREMATION, OR REMOVAL HOLYHOOD, BROOKLINE
ATE OF RACIAL 9-15-20 (Month) (Day) (Year)
19 UNDERTAKER F. J. CROSBY
ADDRESS
20 Burial permit issued by
Official position.
21 Date of issue
19
Registered No.
8223
City or Town
Boston
2 FULL NAME
JAMES J. CONLEY
(If in the Army or Navy of the United Statespgive rank, organization, etc.)
,
MASS.
(Usual place of abode)
32
, M.D.
James F. WILL-1 Sept. 13. 1928
A R-301 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS 1 PLACE OF DEATH County City or Town 2 FULL NAME 200,000 9-25 NO. 2662- 3. 3 SEX Female (b) Name of employer PARENTS Informant 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 14 Filed IN. B .-- WRITE PLAINLY, WITH ONTADING BLACK INAT THIS IS APERMANENT RECORD. Every Rent of information (State or country)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Suffolk
State Massachusetts
Witteop BOSTON
(City or town)
Registered No.
St.,
Ward '
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Rose
atla
187 ChoreDrive
(If in the Army or Navy of the United States, give rank, organization, etc.)
Ward.
Winthrop
(a) Residence. No
(Usual place of abode)
Length of residence in city or town where death occurred
years
6
months
days.
How long in U. S., if of foreign birth?
(If non-resident give city or town and state)
20
years
months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED twrite the word)
Sa If married, widowed or divorced
HUSBAND of
(or) WIFE of
abrahama.
6 AGE
6Years
62
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
Homework
8 BIRTHPLACE (City)
(State or country)
Russia
9 NAME OF
FATHER
Save Wexler
10 BIRTHPLACE OF
FATHER (City)
Russia
11 MAIDEN NAME
OF MOTHER
Miriam Cannotty
teamed
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17 Where was disease contracted
if not at place of death?
Did an operation precede death ?.
200 Date of
200
Was there an autopsy? Funder one vear, was infant Breast Fed ? Ulicial
What test confirmed diagnosis?
(Signed)
M. D.
(Address)
Data
Sept 15%, the
1
(Month)2
(Day)
(Year)
13 B. atlas
(Address)
187 ShoreDrie
Withop
(Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
(Month)
Left
14 1928
(Day)
(Year)
16
HEREBY CERTIFY, That I attended deceased from
May 21
1928, to
Sept 14
1935
that I last saw hy
alive on
Cinq 3
1928
and that death occurred, on the date stated above, at
8
00
m.
The CAUSE OF DEATH was as follows:
-
aucunea
(duration) 1 _yrs. mes. ds.
Lenility
CONTRIBUTORY
(SECONDARY)
Several (duration)
yrs ~- mods
18 PLACE OF BURIAL, CREMATION OR REMOVAL
mt. zion
Melrose
(Cemetery) (City or town)
DATE OF BURIAL
Sept. 161928
19 UNDERTAKER Manuel Stanitaly
ADDRESS Boston
20 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued N.D. Children
Official position
Health Office primit
Date of ISSUB V9/16/2& NO 1277
7-2011
Baston
Winthrop
No.
1.87
Shore Drive
-
-
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
EXTRACTS FROM THE LAWS OF THE "LE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
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 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 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 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, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
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.
may be properly classified. Exact statement of OCCUPATION is very important. PARENTS
13
Informant
Harry Sawtell
(Address)
290 Bowdoin St. Winthrop
14 10/4/28 , 19
Filed
Filed.
Urk. 13
, 19
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
Sept. 20, 1928
(Month) (Day)
(Year)
16
I HEREBY CERTIFY, That I attended deceased from
Sept. 17
28 Sept. 20
28
19
to
, 19
that I last saw h
im
alive on
Sept. 19
19
28
and that death occurred, on the date stated above, at.
5 A.
The CAUSE OF DEATH was as follows: (State fully)
De compensated heart
years
(duration)
yrs.
mos.
de.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
mos.
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
Usual Signs
(Signed)
Allen F. Fehr
M. D.
(Address)
585 Main St, Malden
Date
Sept. 20, 1928
18 PLACE OF BURIAL, CREMATION, OR REMOVAL ridge
Mt. Auburn Crematory (Cemetery) (City or town)
DATE OF BURIAL 9/22/28
19 UNDERTAKER
W. T. White
Registered No. - (City of town) (1
(Place of death)
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
Albert H. Sawtell
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
State
Mass.
City or Town
Winthrop No.
(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
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
Name of
S HUSBAND ? (or) WIFE
Abbie A. McClathan
6 AGE
79
Years
Months 2
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. (b) Name of employer
8 BIRTHPLACE (city or town) West Range
(State or country)
New Hampshire
9 NAME OF
FATHER
Aaron S. Sawtell
10 BIRTHPLACE OF
FATHER (city or town).
(State or country)
New Hampshire
11 MAIDEN NAME
OF MOTHER
Unable to obtain
12 BIRTHPLACE OF
MOTHER (city or town)
(State or country)
$
Malden
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Middlesex
State
Mass.
City or town
Malden
No.
184 Webster
0
0. 4812
28 Registrar of city or town where death occurred
ADDRESS Winthrop
1
Real. 20, 1928
305
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
Medical Examiner's Certificate of Death
Boston (City or town)
1 PLACE OF DEATH
(ISSUED UNDER THE PROVISIONS OF GENERAL LAWS, CHAPTER 38)
County
Suffolk
City or Town
Boston
State
Registered No.
BOSTON CITY CLUB
(Place of death)
( Place of residence)
St ..
Ward
2 FULL NAME
GILBERT THI BFDOptoccurred in a hospital or institution, give its NAME instead of street and number)
(If in the Army or Navy of the Neiced Stop. sivMASSE
(a) Residence. No.
25.TEWKSBURY
(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
3 SEX
M.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
IVi
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
JULIA
6 AGE
Years
63
Months
Days
If less than
1 day ...... hrs.
or ...... min.
IF STILLBORN, enter that fact kere
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
PAINTER
(b) Name of employer
8 BIRTHPLACE (city or town)
DIGBY
(State or country)
N. S.
9 NAME OF FATHER
UNKNOWN
PARENTS
10 BIRTHPLACE OF FATHER (city or town)
(State or country)
NOVA SCOTIA
11 MAIDEN NAME OF MOTHER
UNKNOWN
12 BIRTHPLACE OF MOTHER (city or town)
(State or country)
NOVA SCOTIA
13 Informant
WIFE
(Address)
25 TEWKSBURY ST. WINTHROP
14 Filed OCT 1, 19 28EUMYlenen
Registrar of city or town where death occurred
Filed
Ce6.6. 1928.
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
SEPT 27.
1928
(Month)
(Day)
(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 : NATURAL CAUSES --- CARDIO VASCULAR
DISEASE (CLINICALLY CORONARY
SCLEOR.I.S.). {DI-ED.SUDDENLYWHILEAT WORK)
(See reverse side for additional space)
17 Where was injury sustained
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