USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1938 > Part 66
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RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the ob- servance 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 unrelated to any form of injury. have died without recent medical attendance 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 septi- cemia), 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.
301A
PLACE OF DEATH
SUFFOLK
(County)
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
162
(If death occurred in a hospital or institution,
Ward {
give its NAME' instead of street and number)
2 FULL NAME
Knud P. Tonneson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.East Boston Airport East BostonSt. Mass ...... Ward,
(Usual place of abode)
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred UNKNOWN
months
days.
How long in U.S., if of foreign birth? UNKNOWN
months
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
August.
31
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
August
29th
19 38, to August 31st, 19 38
I last saw him ... allve on .. August .. .31 19.38., death Is sald to have occurred on the date stated above, at ... 44. : 25.FhI The principal cause of death and related causes of Importance In order of onset were as follows: 1.Arteriosclerosis generalized 1922TANT Date of Onset
2.Cerebral Hemorrhage
Aug
.. 29./.38 ...
Contribatory causes of importance not related to principai cause: None
Name of operation
None
What test confirmed diagnosis?
None
Was there an autopsy ?. No.
20 Was disease or Injury in any way related to occupation of deceased?
if so, specify ....
None
(Signed)
JOBTPETRICH
(Address) .Fort ... Banks-
Mass.
Ist It. I.c.USA
DateAug .... 3119.38
21. Hull Village Cemetary,
Hull Mass.
Place of Burial, Cremation or Removal.
DATE OF BURIAL
September
4th
(City or Town)
38
19
22 NAME OF
UNDERTAKI
GEORGE ... H ..... DOWNING
ADDRESS
Hingham .... Mass.
Received and filed ..
43
19
(Registrar)
WUm 11 :36 No. 9080 F
WINTHROP
1
8 SEX
Male
AGE
uw mill, bank, etc ...
OCCUPATION
(State or country)
13 NAME OF
FATHER
UN KNOWN
FATHER (City)
(State or country)
PARENTS
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
17
Informant
(Address)
important. See instructions and extracts from the laws on back of certificate.
in plain terms, so that it may be properly classified. Date of onset and exact statement of OCCUPATION are very
yeer) ...
.UNKNOWN.
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
OF DIVORCED
Married
(write the word)
5a If married, widowed, or divorced HUSBAND of .... Anna .... Tonneson
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 67 Years 2. .Months 20 .... Days
If less than 1 day
Hours
Minutes
8 Trade, profession, or particuler
kind of work done, as spinner, Retired Soldier
sawyer, bookkeeper, etc ...
9 Industry or business in which
work was done, as silk mill,USArmy Retired
10 Date deceased last worked at
1 1 Total time (years)
this occupation (month, and
spent in this
occupation.
3.0
12 BIRTHPLACE (City)
Denmark
14 BIRTHPLACE OF
UNKNOWN (Denmark)
15 MAIDEN NAME
OF MOTHER
Anna Nicholson
Denmark
Relation, if any
REGISTRAR Sta Hosp Ft Banks, Mass ... )
I HEREBY CERTIFY that a satisfactory stendard certificate of death was filed with me BEFORE the burial or trapsit, permit was issued: wohlhaldress (Signature of Agent of Board of Health or other)
an sept /38
(Official Designation) (Date of Issue of Permit)
Boston notefer 9/9/38
NoStation Hospital, Fort Banks, Mass . ... St.,
(If U. S.
War
War Veteran
World
specify WAR)
War
.1938
Date of
M. D.
Statement of occupation. - Precise statement of occupation is very important. so that the relative healthfulness of various pur- suits 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 change on account of the disease causing death. report the occupation prior to illness. If the deceased had retired from bus- iness, report the occupation prior to retirement. Children not gainfully employed may be returned as AT SCHOOL Of 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 oceupation by the appropriate terms, as HOUSEKEEPER-PRIVATE FAMILY, COOK-HOTEL, etc. For a person who had no occupation whatever 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 partic- ular kind of work done and return that, as SPINNER, WEAVER, etc.
In stating the industry or business, avoid the use of such gen- eral 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 ENGIN- EER. 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. . \s principal cause name the disease causing death. . \s 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 importanee in order of onset were as follows:
Date of Onset
Arteriosclerosis
1915
Chronic interstitial nepbritis ....
1921
Cerebral hemorrhage
July 5, 1927
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.
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 sup- posed 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 late 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 perinit shall be issued until there shall nave been delivered to sueh board. agent or clerk, as the case may be, 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 re- quired by law, or in lieu thereof a certificate as hereinafter pro- vided. If there is no attending physician, or if, for sufficient rea- sons, his certificate cannot be obtained early enough for the pur- pose. or is insufficient, a physician who is a member of the hoard of health. or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attend- ing 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 an- other within the commonwealth 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 a removal shall constitute a permit for such removal: provided, that such body shall be returned to the town from which it was re- moved 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 required hy seetion 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 ap- pear 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 elerk of the town for registration. The person to whom the permit is so given and the physician cer- tifying 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. (TER- CENTENARY EDITION.)
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violenec. .- 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 hoard of health or its agent appointed to issue such peinrits, 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. (TERCENTENARY EDITION.)
RULES OF PRACTICE .
The fulfillment of the purpose of these laws calls for the ob- servanee 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 unrelated to any form of injury, have died without recent medieal attendance 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 septi- cemia), and hy the action of chemical (drugs or poisons). thermal. or electrical agents, and deaths following ahortion, 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.
-2
R-302
PLACE OF DEATH
(County)
(City or Town)
No. New .... England Hosp
St.,
........ ..... .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Mary Visconte
(If deceased is a married, widowed or divorced woman, give also maiden name.)
specify WAR)
(a)
Residence.
No
(Usual place of abode)
147.Main
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
4 COLOR OR RACE
(write the word)
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Varr
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
John Visconte
(Husband's name In fully
6 IF STILLBORN, enter that fact here.
AGE 46
Years Months Days
.Hours
Minutes
OCCUPATION
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,
at home
saw mill, bank, etc.
10 Date deceased last worked at
this occupation (month and
year)
/34
11 Total time (years) spent in this occupation. 30
12 BIRTHPLACE (City) (State or country) Gloucester
13 NAME OF
FATHER
David Landry
14 BIRTHPLACE OF FATHER (City)
(State or country)
Gloucester
15 MAIDEN NAME
OF MOTHER
Rose Boudreau
16 BIRTHPLACE OF MOTHER (City) (State or country) Gloucester
17 Informant (Address)
husband
A TRUE COPY.
-
ATTEST:
James Q. Burke
(Registrar of city or town where death occurred) 8/6/38
DATE FILED .. 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
August .3/38
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
7/5/38
19
to
8/3/38
19.
I last saw h
alive on
8/3/38
19
death is said
to have occurred on the date stated above, Gam ......... m. The principal canse of death and related causes of importance in order of onset were as follows:
Dateofonset
polycystio kidneys
uremia
" mos"
Contributory causes of importance not related to principal cause:
pelvio abscess
Name of operation
Exploratory
Date of 1934
What test confirmed diagnosis?
Was there an autopsy?
yes
20 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
DK Scholdell
M. D.
(Address)
New England Hosp
Date
B/3
...
19
21 PLACE OF BURIAL,
CREMATION OR REMOVALInthron ......... Winthrop
(Cemetery)
DATE OF BURIAL
3/5/38
22 NAME OF
UNDERTAKER
W.J. Cassidy
ADDRESS
Boston
Received and filed
19
(Registrar of City or Town where deceased resided)
7 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 PARENTS
important.
50m-9-'31. No. 3385-g
1
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
Registered No
6424
(If U. S.
War Veteran,
163
SEP 15 1924.
City or town) 19
If less than 1 day
-? -
R-302
SUFFOLK BOSTON
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
Registered No .... 65.7Q
No. NewEngland Deaconess Hosp .. St.,
Ward
give its NAME instead of street and number)
2 FULL NAME
George Stevenson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
(Usual place of abode)
115 ... Loring .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
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Varr
5a If married, widowed, or divorced HUSBAND of
Edith Colburn
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
Years
5
Months
Days
19
If less than 1 day
Hours
Minutes
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
warehouse manager
9 Industry or business in which work was done, as sük mill, saw mill, bank, etc.
Metropolitan Storage
10 Date deceased last worked at
this occupation (month and
6/38
11 Total time (years).
spent in this 31
cccupation
12 BIRTHPLACE (City)
(State or country)
Roxbury
13 NAME OF
FATHER
John Stevenson
14 BIRTHPLACE OF
FATHER (City)
Thomaston Me
(State or country)
15 MAIDEN NAME
OF MOTHER
Louisa Short
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Baltimore Md
17
Chester
son
ATTEST: 7
(Registrar of city or town where dcath occurred)
DATE FILED 8/10/38 .19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
... Amust-6 38
(Day)
(Month)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
6/30/38
19
to
19
death is said
to have occurred on the date stated abero attoa
m.
The principal cause of death and related causes of importance in order of onset were as follows:
Datesfonset
pulmonary omboli-multiple
8 5/38
(origin:iliac and femoral veins)
Contributory causes of importance not related to principal cause:
benign prostatic hypertrophy
yrs
suma peste cydotomy and bilaterus faseotor What test confirmed diagnosis? Was there as allons?
20 Was disease or injury in any way related to occupation of deceased?
yes
If so, specify.
(Signed)
A Larble
M. D.
(Address)
81 Bay State Rd
Date
19
21 PLACE OF BURIAL,
CREMATION OR REMOVAL Oak Grove
(Cemetery)
(City or town)
DATE OF BURIAL
8/10/38
19
22 NAME OF
UNDERTAKER
A.E.Long & Son
ADDRESS
Cambridge
Received and filed
SEP 1-5. 1930
19
(Registrar of City or T Town where deceased resided)
important.
50m-9-'31. No. 3385-g
1
3 SEX
M
7
61
AGE
OCCUPATION
PARENTS
Informant
(Address)
A TRUE COPY.
tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
year)
OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
PLACE OF DEATH
(If death occurred in a hospital or institution,
(If U. S.
164
War Veteran,
specify WAR)
8/6/38
19
I last saw 'h
alive on ...
8/6/38
Medford
-
有料
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-11.'36. No. 9080.g
PLACE OF DEATH
Middlesex
(County)
Tewksbury
(City or Town) No .... State.Infirmary.
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
State Infirmary Tewksbury Mass (City or town making return)
Registered No
303
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Wiley Belcher
(If deceased is a married, widowed or divorced woman, give also maiden name.)
specify WAR)
(a)
Residence. No ...
217 Shirley
.St., ..
Ward,
Winthrop
(Usual place of abode)
Length of residence in city or town where death occurred
3
yrs.
1
mos.
19 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
or 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.
AGE
7
81
Years
19
5
Months
Days
If less than 1 day
.. Hours
Minutes
OCCUPATION
8 Trade, profession, or particular
kind of work done, as spinner.
sawyer, bookkeeper, etc.
Fisherman
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)
this occupation (month and
spent in this
occupation.
year)
12 BIRTHPLACE (City)
Winthrop
(State or country)
Mass,
13 NAME OF
FATHER
Samuel Belcher
PARENTS
15 MAIDEN NAME
OF MOTHER
Not learned
16 BIRTHPLACE OF
MOTHER (City)
Raymond
(State or country)
New Hampshire
17 Hospital Records
( Address)
A TRUE COPY
Jammer A. Xifellay, M. S. Supt.
ATTEST :...
(Registrar of city or town where death occurred)
DATE FILED
Aug.
14,
.19.
38
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
August
(Month)
14.
1938
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
July
1935 to.
Aug.
14,
.. 19 ..
38
1 last saw h .... ] Malive on ... Allg.
14,,
.19 .... 3.3, death is said
to have occurred on the date stated above, at ...
9:30 m. P.M.
The principal canse of death and related causes of importance in order of onset were as follows:
Dateafonset
Basal Cell Carcinoma of rt.
Not
.ear
known
Contributory causes of importance not related to principal cause:
Nephritis
Not
mown
Name of operation
Date of
What test confirmed diagnosis?
Clinical
Was there an autopsy?
No
20 Was disease or injury in any way related to occupation of deceased?
If so, specify.
(Signed)
G. J. M. Grant
M. D.
(Address)State Infirmary.
Dat 3 ... 15 .... 19 ... 3.8
21 Winthrop Cem.
Wintrhon
Mass.
Place of Burial .* Cremation or Removal.
(City or Town)
DATE OF BURIAL
August
17,
1938
22 NAME OF
UNDERTAKER
C. R. Bennison
ADDRESS
Winthrop, Lass.
Received and filed
19
-
Relation, if any
-
R-302
1
St.,
Ward
(If U. S.
War Veteran,
165
(If nonresident, give city or town and state)
(write the word)
14 BIRTHPLACE OF
FATHER (City)
Winthrop
(State or country)
Mass.
6
THROPN
SEP 1 71938 AN
R-302
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.
A TRUE COPY.
James Q. Burthe
ATTEST:
(Registrar of city or town where death occurred) 8/18/38
DATE FILED 19
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Div
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
William H LacCullach
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
36
If less than 1 day Hours . Minutes
OCCUPATION|
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc.
private secretary
9 Industry or business in which
work was done, as silk mill.
saw mill, bank, etc.
office
10 Date deceased last worked at
this occupation (month and
7/38
11 Total time (years)
spent in this
occupation
10
12 BIRTHPLACE (City)
(State or country)
Concord N H
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
- Ind
15 MAIDEN NAME
OF MOTHER
Elizabeth Godette
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
- Vt
17
mother
Informaut
(Address)
50m-9-31. No. 3385.4
PLACE OF DEATH
SUFFOLK BOSTON
(City or Town)
No. Mass.General.Hosp
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON (City or town making return)
Registered No ....... 781
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Mary N MooCullagh
(If deceased is a married, widowed or divorced woman, give also maiden name.)
249 Shore Drive
St.,.
..........
...
Ward,
(If nonresident, give city or town and state)
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
18 DATE OF
DEATH
August 15/38
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
7/10/53
19
to
8/15/38
19
I last saw her alive on/15/38.
19
death is said
to have occurred on the date stated above. at ;. Fox .m.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
toute appendicitis with. .. per- foration
1
.mo
Contributory causes of importance not related to principai cause:
pulmonary embolism
"5 min
Mapeut prdevetomy ... with drainage
Data / 4/38
What test confirmed diagnosis?
Was there an autopsy ?..
20 Was disease or injury in any way related to occupation of deceased? If so, specify.
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