USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1939 > Part 85
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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 disahled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is ahsent 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 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.
-301.
1. PLACE OF DEATH
County
Pinellas
3001
Precinet
(Write name, not number)
or
Inc. Town or
City St Petersburg
No. Suwannee Hotel
St.,
_Ward
(If death occurred in s hospital or institution, give Its NAME Instead of street and number)
Length of residence in eity or town where death oeenrred ....... yra .... _5_mos ...... ds. How long in U. S. If of foreign birth ?.... yrs ..... mos ...... ds.
2. FULL NAME -Harriet A Whitney (a) Residence: No. 90 Cottage Ave
St.,-q ==== Ward Winthrop, Mass.
(If nonresident, give elty or town and State)
PERSONAL AND STATISTICAL PARTICULARS
3. SEX
F
4. COLOR OR RACE
White
5. Single, married, widowed or divorced (write the word) Married
5a. If married. widowed or divorced HUSBAND of (or) WIFE of
Charles H Whitney
6. DATE OF BIRTH (month, day and year)
April 22, 1865
7. AGE
Years
Months
Days
If LESS than 1 day, ____ hrs.
74 0
14
or .... min.
8. Trade, profession, or partleular kind of work done, as spinner, sawyer, bookkeeper, etc .....
Housewife
9. Industry or business in which work was done, as silk mill, sawmill, bank, etc. ..
Home
10. Date deceased last worked at this occupation (month,and year) Dec .. 6,1938
II. Total time (years) spent in this 44 oceupatloni
12. BIRTHPLACE (eity or town) (State or country)
England
13. NAME
Booth
14. BIRTHPLACE (city or town)
(State or country)
England
15. MAIDEN NAME Unknown
16. BIRTHPLACE (elty or town)
(Slate or country)
England
17. INFORMANT Charle Writery (Address) written made
Place Winthrop Mass ----- Date-May. 1939
19. UNDERTAKER
(Address)
Bayer ds Inc St Petersburg
20. FILED. 6, 1909
Local Registrar.
21. DATE OF DEATH (month, day, and year) may 6
,1939
22. I HEREBY CERTIFY, That I attended deceased from to January may 6th 1939
I last saw h.AD_alive on
may 5th
539
death is said
to have occurred on the date stated above, at.
The prinelpal cause of death and related causes of importance in order of onset were as follows :
Oste of onset
Coronary homurario
514/391.
Hypertensie Heart Disease
Contributory causes of Importance not related to principal eause :
Name of operation.
Date of ...
What test confirmed diagnosis E.K.G
Was there an autopsy ?.. no
23. If death was due to external causes (violence) fill In also the fol- lowing :
Accident, suicide, or homieide ? Date of injury ........ , 19 ____
Where did Injury oeeur ? (Specify city or town, county, and State) Specify whether injury occurred in industry, In home, or in publie place.
Manner of injury
Naturs of injury
24. Was disease or injury la any way related to occupation of deceased ?... O.
If so, specify
(Signed) N. milton Raquo
M.D.
958 (Address)
205 - Fust Federal But
(Of
100m-9:27
- af lati 1 MOTHER FATHER in plain terms, so that it may be properly classified. Date of onset and exact statement of OCCUPATION are very OCCUPATION important. See instructions and extracts from the laws on back of certificate.
FLORIDA STATE BOARD OF HEALTH BUREAU OF VITAL STATISTICS
CERTIFICATE OF DEATH
NON RESIDENT COPY
State File No.
9465
Registered No.
479
City or Town No ...
(l'audi place Dt abode)
MEDICAL CERTIFICATE OF DEATH
6 th
TOR
٥٠١٨٠٠
"7
0
NOV1500C
PLACE OF DEATH
Pinellas (County)
St Petersburg (City or Town)
No.
Suwannee Hotel
Florida State Board of Health The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
State File # 9465 ( City of town making, relay )
STANDARD CERTIFICATE OF DEATH
Registered No.
479-
f (If death occurred in a hospital or institution. Ward ( give its NAME' instead of street and number) St.,
2 FULL NAME
Harriet A Whitney
(If deceased is a married, widowed or divorced woman, give also maiden name.)
specify WAR)
-
(a) Residence.
No.
90 Cottage Ave.
St.
Ward, ...
Winthrop , Mass.
(If nonresident, give city or town and state)
Length of residence in city of town where death occurred
years
5
months
days.
How loog in U.S., if of foreign birtb?
years
months
days.
PERSONAL AND STATISTICAL PARTICULARS
SEX F
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
If married, widowed, or divorced
'SBAND of
(Give maiden name of wife in full)
Charles Whitney
) WIFE of
(Husband's name in full)
IF STILLBORN, enter that fact here.
74 .Years
April 22, 1565
0 .Months .. 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.
Home
10 Date deceased last worked at
11 Total time (years)
this occupation (month and6
1938
year)
spent in this occupation ..
44
DIRTHPLACE (City)
(State or country)
England
13 NAME OF
FATHER
Booth
14 BIRTHPLACE OF
FATHER (City)
England
(State or country)
15 MAIDEN NAME
OF MOTHER
Unknown
6 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
formant
Charles H. Whitney(
Idress)
Winthrop, Mass.
t-HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health "; "her)
(ficial Designation)
(Date of Issue of Permit)
18 DATE OF
DEATH
May
(Month)
(Year)"
(Day)
6
1.939
19
I HEREBY CERTIFY, That I attended deceased from
January
19 38th May 6th
193.9.
I last saw h ... e.r.
.allve on
May 5th
19.3.9, death is sald
to have occurred on the date stated above, at.
4:00 Am
The principal cause of death and related causes of Importance In order of onset
were as follows:
Date of Onset
Coronary Thrombosis
5/4/39
Hypertensive Heart Disease
10yrs.
Contributory causes of Importance not related to principal cause:
Name of operation
None
What test confirmed diagnosis?
E.K.G.
Was there an autopsy ?.
NO
20 Was disease or Injury in any way related to occupation of deceased?
No
If so, specify
(Signed)
H. Milton Rogers
(Address)
205 First Federadate Bldg. 19
--
21 Winthrop .... .. Mas.s .. May 6th , 1939
Relation, if any
MXXXXXXXX Xx.K & Removal.
(City or Town)
--
DATE OF BURIAL
-----
19
FUNERAL DIRECTOR
22 NAME OF
Baynards Inc St Petersburg
ADDRESS
By I. W. Baynard
Received and filed.
May 6,
19.
39
Wm.M. Davis
A TRUE COPY ATTEST :
E. K.
(Registrar)
(If U. S.
War Veteran
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
...
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 changed 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 occupation 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. 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:
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.
GOVERNING THE
RETURN OF CERTIFICATES OF DEAIn A physician or registered hospital medical officer shall forth- with, alter 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 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 permit shall be issued until there shall nave been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement con- taining the facts required by law to he 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 of a human body, not previously interred, from one town to an- other within the commonwealth cannot be obtained early enough shall make such certificate. If such a permit for the removal 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 hody has been sooner obtained hereunder. 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 ap- pear upon the permit. The hoard of health, or its agent, upon receipt of such statement and certificate. shall forthwith counter- sigu it and transmit it to the clerk 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 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 perntits, 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- 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.
A R-302
uttolkx
PLACE OF DEATH
(County)
KCity gr Tomabrial Hosp
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return) 760
Registered No
214
(If death occurred in a hospital or institution, S
......
Ward
1
give its NAME instead of street and number)
--- Greenstein
(If deceased is a married, widowed or divorced woman, give also maiden name.)
190 Shore Drive
St., ..
Ward,
Winthrop
(If nonresident, give city or town and state)
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED Single
(write the word)
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE Years .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)
11 Total time (years)
spent in this
occupation.
Boston
Everett H Greenstein
14 BIRTHPLACE OF
FATHER (City)
Russia
Sally Cohon
Boston
Radioorif any (
(Registrar of city or town where death occurred)
DATE FILED 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Sent 22/39
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That ! attended deceased from
9/22/39
19
to
19
I Tast saw h
.alive on
Q/22 80
..... m.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateefonset
prematurity-5mos
Contributory causes of importance not related to principal cause:
bilateral atelectasis-virtually complete
Name of operation
Date of
What test confirmed diagnosis?
Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased?
VOC
if so, specify.
(Signed) (Address)C ... A ... Powell
M. D.
Date 19
Hass .K.om.Hosp
9/22/39
21
Place of Burial, Cremation &D.Remavarthi Elcity or Town)
DATE OF BURIAL .
10/15/39
19
22 NAME OF
UNDERTAKER
JI Lovino
ADDRESS
Boston
10/17/39
Received and the Samefind 19
(Registrar of City or Town where deceased resided)
1 No .. 2 FULL NAME 3 SEX M (or) WIFE of 12 BIRTHPLACE (City) (State or country) 13 NAME OF FATHER 15 MAIDEN NAME OF MOTHER PARENTS OCCUPATION 16 BIRTHPLACE OF MOTHER (City) (State or country) 17 Informant (Address) A TRUE COPY. ATTEST: important. 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 50m-11-'36. No. 9080-g N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- (State or country)
(L U. S.
specify WAR)
(a)
Residence.
No
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
St.,
days. How long in U. S., if of foreign birth?
yrs.
9/22/3/19
death is said
to have occurred on the date Stated above, at ... ......
OF TOWA
11 12.
و
6
NOV 291030 AM
IM R-305
PLACE OF DEATH
SUFFOLK BOSTON (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return) 8422
Registered No.
215
-
No ..... "Boston City Losp
2 FULL NAME
(If deceased Is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No
(Usual place of abode)23 Coral Ave
Length of residence in city or town where death occurred
St.,
Ward,
(H.nonresident, give city or town and state)
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
4 COLOR OR RACE
(write the word)
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
inale
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 Hours .Minutes
OCCUPATION
8 Trede, profession, or perticular
kind of work done, es spinner,
sawyer, bookkeeper, etc.
9 Industry or business In which
work wes done, as alk mill.
saw mill, bank, etc.
elovator opr
10 Date deceased last worked at
this occupation (month and
year)
10/50
11 Totel time (years)
spent in this
occupation .....
.7
12 BIRTHPLACE (City) (State or country)
Boston
13 NAME OF
FATHER
PARENTS
14 BIRTHPLACE OFG Nein
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE ofertrude Bloom
MOTHER (City)
(State or country)
Boston
25m.11.'36. No. 9080-h
17
Informant
(Address)
Relation, if any
(
fother
A TRUE COPY.
ATTEST:
James Q: Burke
(Registrar of city or town where death occurred)
DATE FILED 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month) 2/39 (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)
multiple injuries including fractured ribs-pelvis-four-humerus-fibrula
20 If death was due to external causes (VIOLENCE) fill in the following:
Accident,
Suicide or
Homicide?
Date of Injury
10/2/39
.19
Where did Injury occur?
Manner of
and State)
Injury crushed in elevator well Nature of
Injury
Was there an autopsy?
21 Was diseese or Injury in any way related to occupetion of deceased?
If so, specify
(Signed)
M. D.
(Address)
T Leary
Dete 19
Boston
10/2/39
22
Place of Burial. Cremation or Removal.
(City or Town)
LOSes Lontifioro-woburn
DATE OF BURIAL
19
28 NAME OF
UNDERTAKER
10/3/39
ADDRESS
Doston
Received and filed
20/1/98
.19
(Registrar of City or Town where deceased resided)
1
St.,
Ward
5
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
mos.
days. How long in U. S., if of foreign birth?"
1
(If U. S.
War Veteran,
specify WAR)
OF
71 12
130
L
6
5
OR. MA
NOV291933 Ah
M R-302
Essex
PLACE OF DEATH
Heitor Town) Stato Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return) 216
Registered No
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Frank Ligabroedt
(If deceased is a married, widowed or divorced woman, give also maiden name.)
15 Sturgis
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
Jrs.
.St., ..
..........
Ward,
Winthrop
(If nonresident, give city or town and state)
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
whi _e
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
married
5a If married, widowed, or divorced, illie Harris
HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 70
AGE
Years
Months
Days
If less than 1 day
Hours
Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc.
bookkeeper
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
this occupation (month and
year)
Syracuse,
12 BIRTHPLACE (City)
New York
13 NAME OF
Halter bigabroadt
14 BIRTHPLACE OF
New York,
FATHER (City)
I.Y.
Ilelen Woo Truff
New York,
Relation, if any
(
)
(Registrar 'of city or town where death occurred)
10/17/39
DATE FILED .19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
October IN. 1008
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
Sep.
20
1930, 1 ... 046.12.
I last saw her
alive on.
Cot ........ I.D., 19 .... 259 death Is said
to have occurred on the date stated above,'}t.T .:
... m.
The principal cause of death and related causes of importance in order of onset were as follows:
Date ofonset
Chronic nvocarditis
1936
Generalizedarteriosolosis-1954.
Contributory causes of importance not related to principal cause:
Name of operation
Date of
What test confirmed diagnosis?
Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased?
ho
If so, specify.
(Signed) ...... hvorAsoker?
(Address)
M. D.
Deter 7 / 1+1%
of Burial, , Cremation of Rometel. (City or Town)
DATE OF BURIAL
19
22 NAME OF
UNDERTAKER
David Fudge & Son.
ADDRESS.
Received and filed. 19
(Registrar of City or Town where deceased resided)
.....
St.,
Ward
(If U. S. ,
specify WAR)
mos.
days. How long in U. S., if of foreign birth?
mrs.
1
No.
2 FULL NAME
3 SEX
tale
(or) WIFE of
(State or country)
FATHER
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
PARENTS
MOTHER (City)
(State or country)
17
Mary
Informant
(Address)
A TRUE COPY.
ATTEST:
tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
important.
OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
OCCUPATION
50m-11-'36. No. 9080-g
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa-
(State or country)
م
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