USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1928-1930 > Part 65
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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
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
F.
5a If married, widowed, or divorced
Name of
S HUSBAND
2 (or) WIFE
CHARLES
6 AGE
Years
64
Months
7
Days
28
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
AT HOME
(b) Name of employer
8 BIRTHPLACE (city or town)
CARMEL
(State or country)
MAINE
9 NAME OF
FATHER
RUSSEL D. CLEVELAND
10 BIRTHPLACE OF
FATHER (city or town)
(State or country)
MAINE
11 MAIDEN NAME
OF MOTHER
HANNAH E. RUSSELL
12 BIRTHPLACE OF
MOTHER (city or town)
(State or country)
MAINE
13
Informant
MILDRED COLE
(Address)
23 PEARL ST. WAKEFIELD
14
Filed
NOV. 20 1928
ErMSlenen
Filed
11 . 23, 19 28
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
NOV. 18
(Month)
(Day) (Year)
16
I HEREBY CERTIFY,
That I attended deceased from
NOV.
1
19
28
to
NOV. 18
1928
that I last saw h
ER
alive on
NOV. TS
1928
and that death occurred, on the date stated above, as
1.15 A
.m.
The CAUSE OF DEATH was as follows:
(State fully)
RECURRENT CARCINOMA OF BREAST
GENERAL CARCINOMATOSIS
(duration)
yrs ..
mos.
de.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
mos.
.de.
17 Where was disease contracted
if not at place of death
Did an operation precede death
YES
For what.
CANCER OF
Date of operation
3 YRS. AGO
BREAST
Was there an autopsy
YES
What test confirmed diagnosia.
AUTOPSY
(Signed)
G. A. LELAND
(Address)
Date
NOV. 18, 1928
CEDAR GROVE, MILTON
(Cemetery)
(City or town)
19 UNDERTAKER
C. R. BENNISON
DATE OF BURIAL
11-20
, 19 28
ADDRESS
may be properly classified. Exact statement of OCCUPATION is very important. PARENTS
4312
(City or town)
Registered No.
10110
( Place of death) 188
City or town
Boston
No
PALMER MEMORIAL HOSPITAL
pratica, etc.)
(a) Residence.
State
(If in the Army or Navy of the United States Fire rint TEW
1928
H. D.
IRIS IS A PERMANENT RECORD Every Tlem of information should be carofully sup- Paura cole
2200.18.1928
NINANA HIIM
1
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.
20M.
20 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
nor
(Month)
(bay)
(Year)
16
I HEREBY CERTIFY , That I attended deceased from
at birth,19
_, to
19
that I last saw h
alive on
19
and that death occurred, on the date stated above, at The CAUSE OF DEATH was as follows;, (State fully) still
(duration). _yrs. mos ds.
CONTRIBUTO
Breed buth.
(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 If under one year, was infant Breast fed ? What test confirmed diagnosis Louis Diegel (Signed) , M. D.
(Address) 72 Ahits an
Date Man. 27, 1125
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
et Michare Boston
(Cemetery) (City or town)
19 UNDERTAKER
ADDRESS it
Date of Issue cof permit
Permit 11/27/28 1531
R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS 1 PLACE OF DEATH County
Revere notified
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town)
Registered No. 189
City Qr Town
Boston With
No. With Community Hospe St.
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2FULL NAME
yes weh
(If U. S. War Veteran, specify WAR)
Simont morf
(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
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
max
5a If married, widowed cr divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
Months
i
Days
IF LESS than
1 day ......... hrs.
1
1
1
or ........ min.
IF STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
Monthrak.
8 BIRTHPLACE (City) 1
(State or country)
9 NAME OF
FATHER
arthur
PARENTS
10 BIRTHPLACE OF FATHER (City) Lithuania (State or country)
1 1 MAIDEN NAME OF MOTHER MOTHER 220
Kahard gins kol
12 BIRTHPLACE OF MOTHER (City). (State or country) Lithuania
13
Informamos
(Address) 153
14 ed Nos 30/08 (Month) (Day) /(Year) REGISTRAR
Suffolk
State
Massachusetts
Ward
(a) Residence. No.
133
Bellingham si:
Ward,
(If non-resident give city or town and state)
26
1928
m.
ACF paldans Alnieje.
a4 pinoys
2200 - 26, 1925 REVISED UNITED STATESSTANDARD 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 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 reccive 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 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.
R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS 1 PLACE OF DEATH County
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town)
Suffolk
State_Massachusetts
Registered No .. 1,90
.St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Margaret E.
53 Waldemar Que.
St. Ward.
(If non-resident give city or town and state)
months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
Quite
William
-
Months
Days
W 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)
(State or country)
9 NAME OF
FATHER
10 BIRTHPLACE OF
FATHER (City)
(State or country)
reland
11 MAIDEN NAME OF MOTHER Margaret Welch
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
13
Informant
cristine M. Andersen
(Address)
5.3 les alleman (A.M.
14 Filed 2010 128
(Month) (Day) (Year)
REGISTRAR
Acidosis
(duration)
yrs ..
.mos.
18
ds.
DIABETES
Mellinis
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
.mos .. ds
17 Where was disease contracted
if not at place of death?
Did an operation precede death? NO -
Date of
Was there an autopsy?
it under one year, was infant BreastFed ?... What test confirmed diagnosis? Edward Hraman.
(Signed)
(Address)
476 Sharkey
3a
1928
Date
(Month)
(Day)
(Year)
18 PLACE OF BURIAL, CREMATION OR REMOVAQ
Valylo ross qualxen
DATE OF BURIAL Dec 2.1928
(Cemetry) (City or town)
19 UNDERTAKER
l'evid 1. Cooley
ADDRESS
Healle fi
Date of ISSU8 + permit 12/1/28
Permit NO 1540
1
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
Nov
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY, That I attended deceased from
Nov-11.
19 22, to
NOV. 29
, 1928
that I last saw h
en alive on
Nov. 29
, 1928
and that death occurred, on the date stated above, at. 1.30 P. m.
The CAUSE OF DEATH was as follows:
29
1928
5
SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
Sa If married, widowed or divorced
HUSBAND of
(or) WIFE of
1
Anderson
6 AGE 62 Years
Lougester
PARENTS
200,000 9-2 NO. 2662 - 3.
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
-711.
20 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me/ BEFORE the burial or transit permit was issued Hai. S. Children
Official position
53. Waldemar Ave.
City or Town
Boston
Winthrop
No.
Anderson
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
2
years 6
months
days. How long in U. S., if of foreign birth? years
M. D.
margaret " nov. 29. 1928
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 Planter, Physician, Com- positor, Architect, Locomotive engineer, Civil engineer, Stationary fire- man, etc. But in many cases, especially in industrial employmenta, 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- Bions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Ex- haustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia,". "Weakness," etc., when & definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, 86 "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 Hole 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 aa 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 ยท 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 recognised disesge 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.
-305
DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
1 PLACE OF DEATH
(ISSUED UNDER THE PROVISIONS OF GENERAL LAWS, CHAPTER 38)
(City or town)
County
State
withro
No.
hospital or institution, give its NAME instead of street and number)
(a) Residence.
No ..
16 Willow an
St.,
Ward. Withiol
Way
(If non-resident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
20 mos.
3 days How long in U. S., if of foreign birth ?
yrs. mos. days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, or DIVORCED (write the word) Married
Ja If married, widowed, or divorced
HUSBAND of
(or) WIFE of
trans Dominici
6 AGE
Years
Montes
3
Days 6
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.
Housewife
(b) Name of employer
8 BIRTHPLACE (City or town)
(State or country)
9 NAME OF FATHER
England
Robert Radcliffe
PARENTS
10 BIRTHPLACE OF FATHER (City er town)
England
(State or country)
11 MAIDEN NAME OF MOTHER
Wary Hollow
12 BIRTHPLACE OF MOTHER (City or town) England (State or country)
16 I HEREBY CERTIFY that I have made examination of the dead body of the person above named and that to the best of my knowledge and belief the CAUSE AND MANNER of death are as follows: (If an injury was involved, state fully)
aplydiationby Cord about the
neck
suicidal 1
( See reverse side for additional space)
17 In what City or town was injury sustained ?
(Signed)
M. D.
(Address)
Medical Examiner for ......
ZDate
(Month)
(Day)
1928 (Year)
13
Informant
Wuttorp Hopital
18 PLACE OF BURIAL, CREMATION, OR REMOVAL N DATE OF BURIAL
Milvele michael
(Cemetery) (City or town)
(Month) (Day) (Year)
19 UNDERTAKER
Registrar of city or town where death occurred
19 2.9
Registrar of city or town where deceased resided
20 Burial permit issued by ..
21 Date of issue
Permit No ..
2.06
Registered No.
Registered No. Withro stat Hospital
Q" face of residence)
Ward
(If death occurred in 2 FULL NAME ada Roominici
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