USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1933 > Part 84
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The fulfillment 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 un- related to any form of injury, have died without recent medical attend- ance 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.
FORM R-305
1
PLACE OF DEATH
SUFFOLK (County)
BOSTON
(City or Town)
Haymarket Sq Relief
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
212
(City or town making return)
Registered No.
9013
(If death occurred in a hospital or institution, Ward { give its NAME instead of street and number)
2 FULL NAME
JosedeSouza
Oliveira
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual place of abode)
71 ... Segamore .. Ave
St.,
Ward,
(If U. S. War Veteran, specify WAR) Winthrop
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
mos.
days
How long in U. S., if of foreign birth?
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
Or DIVORCED
(write the word)
married
5a If married, widowed, or divorce
HUSBAND of
Maria (Ponte) Oliveira
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
AGE
58
Years
8
Months
21 Days
If less than 1 day Hours Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc. janitor
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
10 Date deceased last worked at 11 Total time (years) spent in this occupation 17
this occupation (montbard 1933
year)
19 | HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully) Internal injuries caused by an accidental fall into an elevator well.
20 If death was due to external causes (VIOLENCE) fill in the following : Accident, Suicide or WAGmicide ?
Date of injury.
19
Where did injury occur ?
Manner of
Injury ..
Nature of
Injury
21 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
G .B. Magrath
M. D.
(Address)
Boston
Date10/30/19 .33
22 PLACE OF BURIAL,
CREMATION OR REMOVAL
Holy Cross
Melden
(Cemetery)
(City or town)
DATE OF BURIAL
Nov
2
19
33
23 NAME OF
UNDERTAKER
Daniel
Jordan
ADDRESS
Cambridge
Received and filed
NOV 7 - 1933
19
(Registrar of City or Town where deceased resided)
MARGIN RESERVED FOR BINDING
25m-2-'30. No. 7997-e
A TRUE COPY.
ATTEST: James J. Mulvey
(Registrar of city er town where death occurred
DATE FILED
NO.V.
6
19.33
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Oct
30
1933
(Month)
(Day)
(Year)
12 BIRTHPLACE (City)
(State or country)
Azoros
13 NAME OF
FATHER
Manuel S Oliveira
14 BIRTHPLACE OF
FATHER (City)
PARENTS,
(State or country) Azores
15 MAIDEN NAME OF MOTHER Francisca deJesus
16 BIRTHPLACE OF MOTHER (City) (State or country) Azores
17 Wife
Informant
(Address)
(City or town and State)
No.
St.
-
ORM R-302
MARGIN RESERVED FOR BINDING
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
PLACE OF DEATH
1.0.101k (County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Norfolk: 213
(City or town making return)
Registered No .. 2.11
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Florence Gladys Peckman (ncc. Thoburn)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
440 Pleansont
St.,
Ward, ...... inthron
(If nonresident, give city or town and state)
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Forale
4 COLOR OR RACE
nite
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
18 DATE OF
DEATH
October 125
1.95.
(Day)
(Month)
(Year)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Give maiden name of. wife in full)
Robert James Decisión
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
58
AGE
Years
Months Days
If less than 1 day Hours Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as simonemaker Proofreader sawyer, bookkeeper, etc ..
9 Industry or business in which work was done, as silk mille ine Composition Co saw mill, bank, etc .....
10 Date deceased last worked at
this occupation (month and
year) ..
1950
11 Total time (years)
spent in this
occupation ..
12 BIRTHPLACE (City)
(State or country)
Canada
13 NAME OF
FATHER
Daniel Thoburn
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Isabel Martin
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
17
Hospital Records
Informant
(Address)
A TRUE COPY.
ATTEST:
Genre FCampbell
(Registrar of city or town where death occurred)
19 33
MEDICAL CERTIFICATE OF DEATH
19 I HEREBY CERTIFY, That I attended deceased from July 31st 33 October 12th, 23 I last saw hralive on hop 15th, 199, death is said 19 to - to have occurred on the date stated above, at.12 :. 10m. P .!!. The principal cause of death and related causes of importance in order of onset were as follows: Carcinya of cervix Dateofonset
17
Contributory causes of importance not related to principal cause:
Name of operation
na .... tom ....
Date 1of 33.
What test confirmed diagnosis?
Was there an autopsy?
0
20 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
M. D.
(Address) (ville Fois ] Date 10/1019
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
It.
(Cemetery)
10/14/55
(City or town)
DATE OF BURIAL
19
22 NAME OF
UNDERTAKER
onurles R. Bennison
ADDRESS
Received and filed
19
egistrat of City or Town where deceased resided)
.
important.
50m-2-'30. No. 7997-
1
Norfolk
(City or Town)
No. Ondville Hospital
.St.,
Ward
(IF U. S.
War Veteran,
specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
13 days. How long in U. S., if of foreign birth? 25
yrs.
(write the word)
....
DATE FILED
Cannot be learned
1
FORM R-301
MARGIN RESERVED FOR BINDING
1 3 SEX ninle (or) WIFE of 7 AGE t Years OCCUPATION, 15 MAIDEN NAME OF MOTHER PARENTS is very important. See instructions and extracts from the laws on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of 12 BIRTHPLACE (City) (State or country) 200M-11-'29. No. 7180-a
PLACE OF DEATH
Suffolk (County) Winthrop (City or Town) Ninthrop Community Hospital . ... St.,
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Winthrop (City or towtf making return)
Registered No. 211
(If death occurred in a hospital or institution,
Ward
give its NAME instead of street and number)
2 FULL NAME Baby Brown
(If deceased is a married, widowed or divorced woman, give also maiden name.)
19 Sagamore Ave
St.,. ........... . Ward,
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
X mos.
days.
How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
XX
5a If married, widowed, or divorced HUSBAND of
2
Z
(Give maiden name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here. Stillborn
Months .Days
If less than 1 day
..... Hours
....... Minutes
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc. 9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
10 Date deceased last worked at this occupation (month and year) .. X 11 Total time (years) spent in this occupation
Winthrop
Massachusetts
13 NAME OF FATHER Willard .R.Brown
14 BIRTHPLACE OF FATHER (City) . (State or country)
Gardner
Masne
Elsie .M. Euville
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
mans .
17 Willard. R. Brown.
Informant , (Address) 19 Say ama an krelling
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the buriat or transit permit was issued:
(Signature of Agent of Board of Health or other)
11/14/33
(Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
October
30
1933
(Year)
(Month)
(Day)
19 I HEREBY CERTIFY, That I attended deceased from
19
, to
19
I last saw h .....
... alive on
19
death is said
to have occurred on the date stated above, at.
m.
The principal cause of death and related causes of importance in order of
onset were as follows:
Dateofonset
still born (8 mos)
Quetrin 1933
Contributory causes of importance not related to principal cause:
none
Name of operation
Date of
yes
20 Was disease or injury in any way related to occupation of deceased? . no
If so; specify
aliraquo m
., M. D.
(Signe
(Address 562 Stanley
MW 4 1933.
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
(Cemetery) 17
City or town)
DATE OF BURIAL
22 NAME OF
UNDERTAKER
CRB!
ADDRESS
Received and filed NCV:
19
A TRUE COPY, ATTEST:
(Registrar)
(If U. S. War Veteran, specify WAR)
(a)
Residence. No.
(Usual place of abode)
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(Official Designation)
Brance
1
19
What test confirmed diagnosis?
clinical towns there an autopsy!
Revised United States Standard Certificate of Death
Statement of occupation .- Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupation had been given up or changed on account of the disease causing death, report the occupation prior to illness. If the deceased had retired from business, report the occupation prior to retirement. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework in answer to Question 8 and own home in answer to Question 9. For a person engaged in domestic service for wages, however, desinate the occupation by the appropriate terms, as housekeeper-private family, rook -hotel, etc. For a person who had no occupation what- ever write none.
To be complete, an occupation return must state:
8 .- The trade, profession, or particular kind of work done.
9 .- The industry or business in which the work was done.
10 .- The month and year the deceased last worked at the occupation. 11 .- The number of years the deceased followed the occupation.
In stating the occupation, avoid the use of such indefinite terms as "employee, " "worker. " "operative," etc. Find out the parti- cular kind of work done and return that, as spinner, weaver, etc.
In stating the industry or business, avoid the use of such general terms as "store," "factory, " mill." etc. State the particular kind of store, factory, mill, etc., as grocery store, soap factory, cotton mill, etc.
Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as civil engineer, mechanical engineer, mining engineer, stationary engineer, etc. Avoid the term "laborer" when a more precise statement of the occupation can be secured. Do not use the word "mechanic, " but give the exact occupation, as carpenter. puinter, machinist, etc. Distinguish carefully between retail merchants and wholesale merchants. A person who sells goods should be called a salesman and not a clerk.
Statement of cause of death .- Cause of death means the disease, injury, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease or injury causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause. Under contri- butory causes of importance not related to principal cause, name other important diseases or injuries.
Example
The principal cause of death and related causes of importance in order of onset were as follows: Arteriosclerosis
Date of onset
1015
Chronic interstitial nephritis
1021
Cerebral hemorrhage
July 5, 1927
Contributory causes of importance not related to principal cause: Fracture of arm
Automobile accident
May 3, 1927
In a group of causes containing the principal cause and related causes, the causes should be given in the order of onset, so that in a group of three causes the principal cause may appear in either first. se od, or third position. The principal cause in the above example happens to be the second cause given.
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 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 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, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, 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 satis- factory 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 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 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 certificate 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 state- ment and certificate, shall forthwith countersign 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 ceme- tery or burial ground in which the interment is made .. . Chap. 114, Sec. 46, G. L., as amended.
State cause for which surgical operation was undertaken. 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, mis- carriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
ORM R-302
SUFFOLK
(County)
1
BOSTON
(City or Town)
No.
Boston City Hospital
.Ward
give its NAME instead of street and number)
2 FULL NAME
Samuel
Harimera
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
(Usual place of abode)
18 .. Edgehill .. Rd
St.,
Ward,
Winthrop
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
mos.
days.
How long in U. S., if of foreign birth?
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Nov
1
(Month)
(Day)
1933
(Year)
19 I HEREBY CERTIFY. That I attended deceased from
29
1933 .. , to.
Nov.
1
19.33 ..
I last saw h
alive on
19
death is said
to have occurred on the date stated above, at.
7.354
m.
The principal cause of death and related causes of importance in order of onset were as follows: cardiac .. hypertrophy.
Dateafonsct yrs.
Contributory causes of importance not related to principal cause:
.pulmonary ... congestion
dys
Name of operation
What test confirmed diagnosis?
Date of
autopsy
Was there an autopsy? yes
20 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
J .... F ... Deich
M. D.
(Address)
Boston
Data 1/1/
33
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Holy Cross
Malden
(Cemetery)
(City or town)
DATE OF BURIAL
NOT.
19 33.
22 NAME OF
UNDERTAKER
M J Kelly
ADDRESS
East Boston
Received and filed
1933
19
DATE FILED
Nov ..... 6
19.33
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON (City or town making return)
Registered No ...
9023
(If death occurred in a hospital or institution,
(If U. S.
War Veteran,
specify WAR)
215
3 SEX
M
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
Or DIVORCED
(write the word)
single
5a If married, widowed, er divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 38 Years Months Days
If less than 1 day
Hours
Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc. physician
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc ..
M D
10 Date deceased last worked at 11 Total time (years) spent in this occupation. 6
this occupation (month and
year)
Nov. 1933
12 BIRTHPLACE (City)
East Boston
(State or country)
Ma SB
13 NAME OF
FATHER
Charles H Fartmere
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass
15 MAIDEN NAME
OF MOTHER
Amie Gleason
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17
Mrs Annie Hartmere
Informant
(Address)
A TRUE COPY.
ATTEST:
James J. Mulvey
(Registrar of city oftown where death occurred
50m-2-'30. No. 7997-đ
PLACE OF DEATH
MARGIN RESERVED FOR BINDING
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
important.
DEC 8
(Registrar of City or Town where deceased resided)
ORM R-302
SUFFOLK
(County)
BOSTON
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No .....
9076
(If death occurred in a hospital or institution,
Ward
give its NAME instead of street and number)
Elizabeth
Whitman
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
(Usual place of abode)
75 .Buchanan
St.,
Ward, ... Winthrop.
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
widow
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE
Ernest Whitman
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 62 Years 2 .. Months. 12 Days
If less than 1 day
.Hours
Minutes
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc. nurse
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
hospital
10 Date deceased last worked at
this occupation (month and
year) ..
11 Total time (years)
spent in this
occupation ...
20
Nova Scotia
13 NAME OF
FATHER
Alexander NoDonald
Scotland
Elizabeth Morrison
Scotland
Informaat
Mary H McDonald
James J. Mulvey
(Registrar of city (town where death occurred
Nov.
6
.1933
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Nov
2
1933
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
Aug. ...... 27
19 ... 33 to
.Nov.
1
19.33.
l last saw h ... Or ... alive on.
NOT.
1
133 ... , death is said to have occurred on the date stated above, at. 12 .. 554 .. The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
acute myeloogenous
24.mos
leukemia
Contributory causes of importance not related to principal cause:
marked anemia
Name of operation
What test confirmed diagnosis? ..
lab
Was there an autopsy? no.
20 Was disease or injury in any way related to occupation of deceased?
no.
If so, specify.
(Signed)
F.B.Brigham
M. D.
(Address)
Boston
Data 1/2/
19 33-
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Camp Hill
Nova Scotia
(Cemetery)
(City or town)
DATE OF BURIAL
19
22 NAME OF
UNDERTAKER
C R Bemison
ADDRESS
Winthrop
Received and filed.
DEC 8 ****- 19331.19.
(Registrar of City o
Town where deceased resided)
MARGIN RESERVED FOR BINDING
1 No. 2 FULL NAME 3 SEX F 12 BIRTHPLACE (City) (State or country) 14 BIRTHPLACE OF FATHER (City) 15 MAIDEN NAME OF MOTHER PARENTS OCCUPATION 16 BIRTHPLACE OF MOTHER (City) (State or country) 17 (Address) A TRUE COPY. ATTEST: ...... important. DATE FILED 50m-2-'30. No. 7997-d N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE (State or country)
PLACE OF DEATH
Palmer ... Memorial ... Hospital
St.,
(LE U. S. War Veteran,
216
specify WAR)
(write the word)
Date of
ORM R-301
MARGIN RESERVED FOR BINDING
OCCUPATION is very important. See instructions and extracts from the laws on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of PARENTS 100m-11-'30. No. 605-b
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