USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1941 > Part 22
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No undertaker or other person shall bury a human body or the ashes thereof which bave 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 beld, 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 observ- ance 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 ill- ness 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 discase un- related 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 septice- mia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting fromn injury or infection related to occupa- tion, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Canse 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 moroid con- ditions, if any, related to the principal cause and any important complication of the principal cause.
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 usual occupation prior to illness. If the deceased had retired from busi- ness, report the usual 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. 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.
SPACE FOR ADDITIONAL INFORMATION
FORM R-306
PLACE OF DEATH No
/County)
(City or Town 115 Surmet Case
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS AFFIDAVIT AND CORRECTION OF A RECORD OF DEATH
(City or town making return)
Registered No. 61
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(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?
5
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
Which
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Angle
Ba 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
9
Months
AGE 51
Years
5
Days
If less than 1 day
Hours
Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc.
Forelade
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
Candy Info
10 Date deceased last worked at
this occupation (month and
year)
Total time (years)
spent in this
occupation ...
12 BIRTHPLACE (City)
021-05 -- 7341
(State or country) Estland
15 MAIDEN NAME
OF MOTHER
NAME Martha Englisch
Liverpool
16 BIRTHPLACE OF MOTHER (City) (State or country) England
17
Informant ...
(Address) 15 dumine an Muito
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: C
2. Children ...... (Signature of Agent of Board of Health or other)
Heath Office 4/1/41 (Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATHI
18 DAT
OF March 30, 1941
DEATH
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from november 1940, march 30 19.54 ...
I last saw h.&Aalive on
march 28
41
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: aceite Canary Thrombosis 3 day
Dateofonset
A
arteriosclerosis
1 year
Hypertension
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?
If so, specify
Jacob Celerome m.D
(Signed)
M. D.
(Address) 562 Steiley D
Data/3/
.. 19 .54/
21 PLACE OF BURIAL,
net Solvay Cem
CREMATION OR REMOVAL
(Cemetery ). Royal City of town
DATE OF BURIAL
april 2
41
19.
22 NAME OF
fahrll Lynchan
UNDERTAKER
357 Min th Medfad
Received and filed.
.....
agent
3
19 ......
A TRUE COPY, ATTEST: (Registrar)
1 2 FULL NAME 3 SEX Female (or) WIFE of OCCUPATION 13 NAME OF FATHER 14 BIRTHPLACE OF FATHER (City) PARENTS N. B .- WRITE PLAINLY WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information should be carefully supplied. AGE should be stated EXACTLY. See reverse side for affidavit. (State or country) 20m-2-'30. No. 8053-c
affidavit non MARGIN RESERVED FOR BINDING
Ca
Ward
Mcknight
(H deceased is a married, widowed or divorced woman, give also maiden name.)
115 Semment Castro
Ward,
(If nonresident give city or town and state)
DEPOSITION WRITE LEGIBLY WITH DURABLE BLACK INK
The Commonwealth of Massachusetts -
ss .:
County of.
The undersigned, being duly sworn, depose and say that the record relating to the death
of
in the of. (Name of city or town) ., (Give name of decedent exactly as recorded on the original record) (City or town)
does not fully and correctly state all the facts relating to said death, and that the true state- ment of facts omitted or incorrectly stated in said record has been supplied by ......... on the (Him or her) form of certificate on the other side of this blank.
SIGNATURE
RESIDENCE
Relation to decedent, (City or town, street and number, if any) 3.57 Mainst Medford Was Underlaks.
Date,
Then personally appeared before me the person whose signature appear above and made oath that the statements subscribed to by. are true.
Name
Official designation
(City or town clerk or assistant clerk)
MARGIN RESERVED FOR BINDING
M R-301 A =
PLACE OF DEATH
Suffolk
The Commonwealth of Massarqusetts 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
62
§ (If death occurred In a hospital or institution, { give its NAME instead of street and number)
(If U. S. War Veteran. specify WAR).
(If deceased is a married, widowed or divorced woman, give also maiden name.)
365 Revere St., Winthrop
St
(If nonresident, give city or town and state)
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed. or divorced
HUSBAND of ..
Edwina Stokes Gregory
(Give maiden name of wife in full)
(Husband's name in full)
42
.years
If less than 1 day Hours.
Minutes
Jeanette Sommons
17 Mrs. Edwina S. Gregory Wife
(Address)
365 Revere St., Winthrop, Mas ..
I HEREBY CERTIFY that a gatisfastopy standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board - Healthor other) Health Office 4/7/41
Official Designation) (Date of Issue of Rermit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
March
31
1941
(Month)
(Day)
(Year)
I.HEREBY CERTIEX That I attended deceased from
October 3/ 1939
to .. March 31, 19.41
I last saw hun alive on march 31, 1941, death is said to have occurred on the date stated above, at 11:40 9: m.
Immediate cause of death Cerebral Hemontage
Duration IMPORTANT 9 hours
Due to
Carterischervais
2 years
Due to.
to Chiscenic Interstitial
neplantes
Other conditions.
(Include pregnancy within 3 months of death)
IMPORTANT
PHYSICIAN
Major findings:
Of operations
none
Of autopsy
not done
... Date of ...
What test confirmed diagnosis? Chanical & matory
20 Was disease or injury in any way related to occupation of deceased? no
If so. specify ......
(Signed)facut
(es) 562 Stunden Vate 3/31 1/41.
podlawhen torrent tudo. Mars
Place of Burial, Cremation or Removal. City or Town)
DATE OF BURIAL.
April 2 1941
19
22 NAME OF
Richard 16. Withits
FUNERAL DIRECTOR.
ADDRESS
147 Winthrop St., Winthrop
Received and filed APR 3 1941 ..... 19
(Registrar)
(County) 1 Winthrop (City or Town) No. 2 FULL NAME Edward S.Gregory (a) Residence. No. (Usual place of abode) Length of stay: In hospital or institution ...... ospital Ree 3 SEX 4 COLOR OR RACE Male White Edwina (or) WIFE of. 6 Age of husband or wife if alive. 7 IF STILLBORN, enter that fact here. 8 Days AGE .Years .Months Usual Tax Consulant 9 Occupation :....... Industry 10 or Business: Office 11 Social Security No .... none 12 BIRTHPLACE (City) Gardner (State or country) 14 BIRTHPLACE OF Winchedon FATHER (City) Mass. (State or country) 15 MAIDEN NAME OF MOTHER PARENTS MOTHER (City). (State or country) Mass. 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 allection in aga made by 16 BIRTHPLACE OF Athol 100m-2-'40-D-729-8 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of 13 NAME OF FATHER George G.Gregory
Winthrop Comunity Hospital
St.
1
days.
In this community
30
yrs.
mos.
days.
years
months
Relation, if any
"Everest. Mtas
Underline the cause to which death should be charged sta- tistically.
2years
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, 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 liealth, 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 receiv- ing 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 satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory 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 in- sufficient, a physician who is a member of the board of health, or em- ployed 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 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 removal shall constitute a permit for such removal; 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 forin for the re- moval of such body 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 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).
No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made. .. . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
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) Bcard of Health physicians will certify to such deaths only as those of persons who, thougli 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 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.
Statement of Cause of Death .- Cause of death means the disease, or complication which causes death, rof 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.
Statement of Occupation .- Precise statement of occupation is very importart, 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 usual occupation prior to illness. If the deceased had retired from business, report the usual 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. 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.
SPACE FOR ADDITIONAL INFORMATION
-
M R-302
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
PARENTS
(State or country)
15 MAIDEN NAME
OF MOTHER
Ann Burns
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Husband
Relation, if any
Informant.
(Address)
.
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
3/6/41
19
MEDICAL CERTIFICATE OF DEATH
3 SEX
fem
4 COLOR OR RACE| 5 SINGLE
(write the word)
MARRIED
white
WIDOWED
or DIVORCED married
18 DATE OF
DEATH.
(Day)
Month arch 4 1947
(Year)
19
IHEREBY CERTI.
Mar 4
19.
LFY.
That
3/4eted deceased from
19.
I last saw h ............ alive
3/4/41
19
death is said
to have occurred on the date stated above, at ..
4/354
Immediate cause of death.
myocardial infarction
10hrs
8
AGE
42
Years.
Months.
.Days
If less than 1 day
Hours.
Minutes
Usual
9 Occupation:
at home
Industry 10 or Business:
Il Social Security No.
12 BIRTHPLACE (City)
Ireland
(State or country)
Other conditions gen arterio sclerosis-yrs (Include pregnancy within 3 months oi death)
PHYSICIAN
Underline the cause to which death should be charged sta- tistically.
Of autopsy
What test confirmed diagnosis ?
20 Was disease or Injury In any way related to occupatloo of deceased ?
If so, specify.
(Signed)
H A Benjamin
M. D.
(Address)
Boston
Date
3/4/ 1941
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Holy Cross Malden
DATE OF BURIAL.
March 6 1947
... 19 ..
22 NAME OF
FUNERAL DIRECTOR
E .... E .... Burns
ADDRESS
Malden
Received and filed 19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 8427-f
1
PLACE OF DEATH
(County) BOSTON
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No ..
2437
-
No .......
Peter Bent Brigham Hosp
St. 1
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mary.
Eichorn
(If deceased is a married, widowed or divorced woman, give also maiden name.)
270 Main
.....
St.
Winthrop Mass
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
years
months
days.
(If nonresident, give city or town and state)
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
5a lf married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
John .C.Eiohorn
(Husband's name in fu
6 Age of husband or wife if alive. 45
Years 7 IF STILLBORN, enter that fact here.
Due to
hypertensive cardio vascular
disease
5 yrs
Due to
13 NAME OF
FATHER
Bernard Sheridan
14 BIRTHPLACE OF
FATHER (City)
Ireland
Major findings :
Of operations
Date of
Duration
to ....
(If U. S.
War Veteran,
specify WAR)
63
(Cemetery)
(City or Town)
5
·ANTHROP MAS
APR 11 1941 Mt
1 R-302
PLACE OF DEATH
SUFFOLK (County) BOSTON
(City or Town)
No. Mass General Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No ..
3414
(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
.Mar.jor.1.0 ..
.W.1.1 .. 1.8
(If deceased is a married, widowed or divorced woman, give also maiden name.)
46 Seymouth
St.
Winthrop Mass
(If nonresident, give city er town and state)
...
years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
April 2 .... 1.941
(Month?
(Day)
(Year)
19 I HEREBY CERTIFY.
2/24/41
19
19
4/2/41
19 ..
.....
death is said
That
4 attended deceased from
I last saw h ........... alive on.
to have occurred on the date stated above, at.
1/35A
Duration
Immediate cause of death. pulmonary .... metastatic .... carcinoma with effusion
Due to ... carcinoma ... o.f ..... breast ..
recurrent
6 .... yrs
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Date of.
Of autopsy
..
What test confirmed diagnosis ?.
20 Was disease or injury in any way related to occupation of deceased ?
If so, specify
(Signed)
WTS Thorndike
M. D.
(Address)
Boston
Date
19
21 PLACE OF BURIAL.
CREMATION OR REMOVAL
Winthrop
Mass
DATE OF BURIAL
ASSET7 4 194](City or Town)
19
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
RH White
Received and flod. Winthrop 19
DATE FILED
4/4/41
... 19.
(write the word)
widowed
of wife in full)
(or) WIFE of
(Husband's name in full)
years
If less than 1 day
Hours
Minutes
at home
George Ritchie
Marjorie Burnett
Scotland
Relation, if any .( ......... s.on .......
A TRUE COPY.
ATTEST
(Registrar of city or town where death occurred)
3 SEX 4 COLOR OR RACE 5 SINGLE MARRIED WIDOWED or DIVORCED fem white 5a If married, widowed, or divorced HUSBAND of 6 Age of husband or wife if alive. 7 IF STILLBORN, enter that fact hero. 8 ÅGE. .50.Years. 1 Months. 2 baya Usual 9 Occupation: Industry 10 or Business: 11 Social Security No. 12 BIRTHPLACE (City) (State or country) Scotland 13 NAME OF FATHER 14 BIRTHPLACE OF FATHER (City) 15 MAIDEN NAME OF MOTHER 16 BIRTHPLACE OF PARENTS MOTHER (City) (State or country) 17 Douglas W1118 Informant. (Address) 50m-10-'39. No. 8427-f Copies of feturas of deaths which occurred in your city or town in case the deceased resided in another city or town at the time (State or country) Scotland after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
1
(a) Residence. No ......
(Usual place of abode)
Length of stay: In hospital or institution
(Specify whether)
(If U. S.
War Veteran,
specify WAR)
mo.s.
Underline the cause to which death should be charged sta- tistically.
(Registrar of City or Town where deceased resided)
76 5
THIMORAES
APR111941 Mt
. ..
4
I R-301 A Suffolk.
1
PLACE OF DEATH
2(County) Ventprop (City or Town)-
The Commonturalth 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. 65
No. Canné Freedman
2 FULL NAME
(If deceased ia a married, widowed-or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or Institution
( Before death)
(Specify whether)
yeara
months
days.
In this community
/7 yrs.
mos.
dayı.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE|
Hemale &Chite
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Marked
5a If married, widowed, or divorced HUSBAND of ...
(or) WIFE of
(Ilushand's name in full)
6 Age of husband or wife If alive
70
years
7 IF STILLBORN, enter that fact here.
8 58 Y AO Years Months. Deys
If less than 1 day
Hours
Minutes
Usual
9 Occupation :
House-Heute
10 or Business :
Industry
at Home
11 Social Security No ..
none
Other conditions
Diabetis
(Include pregnancy within 3 months of death)
IMPORTANT
Physician Underline the cause to which death should be charged sta- tistically.
20 Was disease or injury in any way related to ocoupation of deceased ?........
If so, specify.
(Signed)
Edward X. tranger
M. D.
(Address) 200 Was twenty Date Abs. 5 194
21
Tiereth Parael
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
Pas. 6
19 41
22 NAME OF
FUNERAL DIRECTOR
Jacob. H. Leve
ADDRESS
394
Mashington St Dor
Received and filed
19
(Official Designation) (Date of Issue of Permit)
18 DATE OF
DEATH
April
1941
( Month)
(Day)
(Year)
19 | HEREBY CERTIFY, That 1 , attended deceased from January 1939
to.
Abril-
4º
1941
I last saw h. E !!!
.allve on
April-4., 194%, death is sold to
have occurred on the date stated above, at
9.30
A
Immediate cause of death.
Pectoris
Duration IMPORTANT
1 hour
Due to.
ArTerio - Seler0518
Due to.
12 BIRTHPLACE (City)
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