Town of Winthrop : Record of Deaths 1928-1930, Part 65

Author: Winthrop (Mass.)
Publication date: 1928
Publisher:
Number of Pages: 1296


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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