USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1937 > Part 31
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RULES OF PRACTICE
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.
IRM R-302
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
1
Rutland
(City or Town) Rutland State Sanatorium
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Rutland (City or town making return)
Registered No.
43
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Ethel Reese
(If deceased is a married, widowed or divorced woman, give also maiden name.)
81 Fremont
.St.,
......
Ward,
inthron,lass.
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
1 m. 6 mos. 6
days. How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
AGE
27
Years
8
Months
25
Days
If less than 1 day Hours Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
Stenographer
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)
11 Total time (years) spent in this occupation
12 BIRTHPLACE (City)
(State or country)
Mass.
13 NAME OF
FATHER
John Reese
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country) New Jersey
15 MAIDEN NAME
OF MOTHER
Mary Quinn
16 BIRTHPLACE OF MOTHER (City) (State or country) Ireland
17 State sanatorium Records Informant (Address) Rutland, ass.
A TRUE COPY. ATTEST: LouiM. Sauf (Registrar of city or town where death occurred) March 23,1937 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
March 23,
1937
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from September 17 35 March 23 37
19
to.
19
I last saw h er alive on
to have occurred on the date stated above, at2:05 P .M.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
Pulmonary tuberculosis
June , 1928
Contributory causes of importance not related to principal cause:
None
Name of operation
Iceoscopical
Date of
What test confirmed diagnosis?
Was there an autopsy? II.O.
20 Was disease or injury in any way related to occupation of deceased? Inknown
If so, specify
(Signed)
R. Delphina Mccarthy
. M. D.
(Address) Rutland State SanDate
3/2519 .5.0
21 PLACE OF BURIAL
CREMATION OR REMOVAL
(City or town)
19
DATE OF BURIAL
Winthrop, "inthrop, Mass
(Cemetery)
March 26.d.
22 NAME OF
UNDERTAKER
C . P. Ben
ADDRESS
Vingro
Received and filed
1 21937
WINTHROP. MAS
Fon
MOL
19
DATE FILED
important.
50m-9-'31. No. 3385-K
PLACE OF DEATH
Worcester (County)
No.
St.,
Ward
(If U. S. War Veterans, specify WAR)
(a)
Residence. No.
(Usual place of abode)
(Give maiden name of wife in full)
March 23 37 death is said
Boston
I R-301
Every item of
1
PLACE OF DEATH
(County) Winthrop
(City or Ton) 275 Piver Rel
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
Registered No
74
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
275 Pures Reto
St.,
Ward,
(If nonresident, give city or town and state)
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
18 DATE OF DEATH March 27 1937
(Month)
(Day)
(Year)
5a If married, widowed, or divorced HUSBAND of andShe maiden name
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 62
AGE ..... .. 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.
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc .......
at home
10 Date deceased last worked at
this occupation (month appare".
year)
1 Total time (years) spent in this occupation
40
12 BIRTHPLACE (City) .......
(State or country)
Palandt
18 NAME OF
FATHER
Isaac de Josephson
14 BIRTHPLACE OF
FATHER (City)
Poland
(State or country)
15 MAIDEN NAME OF MOTHER Anne Rice (unknown)
16 BIRTHPLACE OF
MOTHER (City)
...
Poland
(State or country)
17 Jura Brockman Relation, if any
Informant (Address) 225- Ring Rd.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
It-
(Signature of Age of Board of Health or other) mar. 27/3/
(Official Designation) (Date of Issue of Permis)
19
I HEREBY CERTIFY, That i attended deceased from
tan
1936, to Mark 27, 1937
I tast saw h. et
.. alive on
marzy
. 1937, death is said
to have occurred on the date stated above, at : 45Am.
The principal cause of death and related causes of Importance in order of onset
were as follows:
Date of Onset
Car cinema of colon
1 april 19 je
(rigmand)
Contributory causes of importance not related to principal cause:
Name of operation & provatony .Dat June 2, 1936 What test confirmed diagnosis? It Was there an autopsy? Ao
20 Was disease or injury in any way related to occupation of deceased? ration
If so, specify Henry Baker M. D.
(Signed)
(Address)
480 Beacon Al
Date
May 27 1937
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
DATE OF BURIAL
22 NAME OF UNDERTAKER
ADDRESS 344 Washington Lever
Received and filed. 19
A TRUE COPY, ATTEST:
(Registrar)
100m-12-'34. No. 2938-0
-- 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 .. . .... . .
Sufrek
NO ......
St ............
Ward
Minnie Brockman
(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.
days.
How long in U. S., if of foreign birth?
45
(City or town)
PARENTS
Reface giftet watts standard Certificate of pcaun
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, designate the occupation by the appropriate terms, as housekeeper-private family, cook-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, cotloss 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. . painter, 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, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease 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 contributory causes of importance not related to principal cause, name other important diseases.
Example
The principal cause of death and related causes of importance in order of onset were as follows: Arteriosclerosis
Date of onset
Chronic interstitial nephritis
Cerebral hemorrhage
July 9, 1927
1
Contributory causes of importance not related to principal cause:
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, second, or third position. The principal cause in the above example happens to be the second cause given.
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. Lows, 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 such a permit for the removal of a human body, not previously interred, from one town to another within the common- wealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such re- møval; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the death certificate contains a recital, as re- quired 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 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., (Tercentenary Edition.)
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., (Tercentenary Edition.)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observanos 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 n 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 recogni and those of persons found dead.
M R-302
Middlesex
(County)
Melrose
(City or Town)
Melrose Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Melrose
(City or town making return)
25
Registered No.
(If death occurred in a hospital or institution, 5 Ward
give its NAME instead of street and number)
2 FULL NAME
Bertha Mary Drury
(Messenger)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
63 Loring Road
(a)
Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
19 days.
How long in U. S., if of foreign birth?
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
Adelbert Nidenpame of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
Years
5
Months
7
Days
If less than 1 day
Hours
Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc.
Housewife
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
Own Home
10 Date deceased last worked at
11 Total time (years)
spent in this
occupation
1
Argyle Sound, Yarmouth
12 BIRTHPLACE (City)
(State or country)
Nova Scotia
13 NAME OF
FATHER
Lorenzo Messenger
Argyle Sound, Yarmouth
Nova Scotia
Katherine Fleming
Shelbourne City
(State or country)
Nova Scotia
17
Adelbert N. Drury
(Addres
63 Loring Road, Winthrop
(Registrar of city or town where death occurred)
DATE FILED
April 5, 1937
19.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
March 31, 1937
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
to ..
March 13, 1937
19
March 31, 1937
.19
I last saw h ... er ... alive on
March ... 31 ... 1937, 19
death is said
to have occurred on the date stated above, at.
6 ₽
.. m.
The principal cause of death and related causes of importance in order of
onset were as follows:
Typhoid Fever
3/2 /3afonset
f
Contributory causes of importance not related to principal cause:
Hypostatic Pneumonia
3/30/37
Name of operation
Date of
What test confirmed diagnosis?
Widal StoolWasthere are topsy no
20 Was disease or injury in any way related to occupation of deceased?
no
If so, specify.
Edward G. Thorp
(Signed)
(Address)
Melrose, Mass.
Date
4/31/33
M. D.
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Green Grove, Yarmouth, N
Camp
(City or town)
S.
DATE
OF BUREL . ....
April 5, 1937
19
22 NAME OF A. E. Long & Son Inc.,
CONDERTAKER w Malden, Mars.
ADDRES
Received and filed 19
(Registrar of City or Town where deceased resided)
1
No.
3 SEX
Female
(or) WIFE of
7
AGE
31
this
year) ..
14 BIRTHPLACE OF
FATHER (City)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
OCCUPATION
PARENTS
MOTHER (City)
Informast
A TRUE COPY
ATTEST :.
tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important.
50m-2-'30. No. 7997-đ
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa-
(State or country)
PLACE OF DEATH
St.,
(L U. S.
War Veteran,
specify WAR)
St.,
Ward,
Winthrop
(If nonresident, give city or town and state)
RM R-302
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
SUFFOLK (County) BOSTON
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
226016
(If death occurred in a hospital or institution,
.Ward
give its NAME instead of street and number)
2 FULL NAME
Baby Daly
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
(Usual place of abode)
26 Beacon
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
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
OF DIVORCED
Single
5a If married, widowed, or 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 Years Months Days
If less than 1 day
3 .... Hours
Minutes
OCCUPATION
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)
11 Total time (years) spent in this occupation
12 BIRTHPLACE (City)
(State or country)
Boston
Mass
13 NAME OF
FATHER
Francis Daly
14 BIRTHPLACE OF
FATHER (City)
Holyoke
Mass
15 MAIDEN NAME
OF MOTHER
Isabel T Flynn
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston
Mass
17 Francis Daly (Father)
Informant H
(Address)
26 Beacon St., Winthrop
A TRUE COPY
Huida Ofedition Juices
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED 3-1-37
19.35
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Feb
.24 1937
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
2-24-37
19
[ last saw h.
im alive on
2-24-37
19
death is said
to have occurred on the date stated above, at ....... 0.2Pm.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
Prematurity (62 months)
2 .- 24.
13.7
Contributory causes of importance not related to principal cause:
Name of operation
What test confirmed diagnosis?
Date of
Was there an autopsy ?.
Yes
20 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
D 1 Levine
M. D.
(Address)
202. W Newton St.
Date.2 .-. 2.4-19.37
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Winthrop-Winthrop
(Cemetery)
(City or town)
DATE OF BURIAL.
2-27-37
1935
22 NAME OF
UNDERTAKER
Kirby Bros.
ADDRESS
170 Winthrop St., Winthrop
Received and filed 19.85 .........
(Registrar of City or Town where deceased resided)
important.
50m-9-'31. No. 3385-g
1
(City or Town) No. Evangeline Booth Hospitalst.,
(If U. S.
War Veteran,
specify WAR)
(write the word)
PARENTS
(State or country)
. to
2-24-37
19
RM R-305
PLACE OF DEATH
SUFFOLK (County)
BOSTON (City or Town) No. en route to Mass Gen Hosptst.,
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON (City or town making return)
Registered No. 2218
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Jane Martineau
(If deceased is a married, widowed or divorced woman, give also maiden name.)
52 Bartlett Road
St.,
Ward,
Winthrop
(If nonresident, give city or town and state)
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Give maiden name of wife in full)
Edmond Martineau
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
AGE
5.7
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.
At Home
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
None
10 Date deceased last worked at
this occupation (month and
year)
11 Total time (years)
spent in this
occupation.
12 BIRTHPLACE (City)
Boston
(State or country)
Mass
13 NAME OF
FATHER
Fergus White
14 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass
15 MAIDEN NAME
OF MOTHER
Margaret F Shannon
16 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass
25m-2-'30. No. 7997-0
17
Elizabeth Burns (Sister)
Informant
(Address)
52 Bartlett Rd, Winthrop
A TRUE COPY
Heide Ofedition Quick
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED 2/27/37
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Feb
24 1937
(Month)
(Day)
(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)
Arterio Sclerotic Heart Disease
Diabetes Mellitus Collapsed while on way to Hospital
20 If death was due to external causes (VIOLENCE) fill in the following :
Accident,
Suicide or
Homicide ?
Date of Injury.
19
Where did injury occur ?
(City or town and State)
Manner of
Injury
Nature of
Injury
21 Was disease or injury in any way related to occupation of deceased? If so, specify.
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