USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1943 > Part 45
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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 heen 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 nece+ sary information which can be obtained as to the deceased, or us to the manner of 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 ashea thereof which have been brought Into the commonwealth until he has re- ceived a permit so to do from the board of health or its sgent 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 he held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made .... Cbap. 114. Sec. 46. G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies of only such persons as sre supposed to have died by violence. If a medical examiner has notice that there is within his county the hody of such a person, he shall forthwith go to the place where the body lies aud take charge of the same; ... - General Laws, Chap. 38, Sec. 6.
RULES OF PRACTICE
The fulfillment of the purpose of these lawa calla for the observance of the following rules of practice :
(1) Attending phyalcians will certify to such deatha only aa those of persons to whom tlicy have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physlolans 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 phyaf- cian is absent from home when the certificate of death is needed.
(3) Medloal Examiners will Investigate and certify to all deaths sup- posably due to Injury. These include not only deaths caused directly or in- directly by traumatism (including resulting septicemla), and by the actlon of clientical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from dlacasa 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 deathi meana 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 caualng 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 ia very 1m- portant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every persou aged 10 years or over. If the occupation had been given up or changed on account of the discase causing death, report the usual occupation prior to Illness. If the deceased hsd retired from business, report the usual occupation prior to retirement. Children not gainfully employed may be returned aa at school or at home. For a woman whose only occupatiou was that of home housework, write housework. For a person engaged in domestic service for wages, however, designste the occupation by the appropriate terma, aa housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
IR-302
PLACE OF DEATH
Suffolk (County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
REVERE
(City or town making return)
1
Revere (City or Town)
No. 237 Endicott Ave Hillside Home
(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
John L Jones
(If deceased is a married, widowed or divorced woman, give also maiden name.)
124 River Rd.
Winthrop
(a) Residence. No.
(Usual place of abode)
Conv. Home
24
(If nonresident, give cfszor town and State)
Length of stay: In hospital or institution.
(Before death)
(Specify whether)
years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
(Month)
(Day)
(Year)
Q I HEREBY CERTIFY
19+
June
That
attended deceased,f
from
1m
I last saw h
alive on
June 2000 1%
43
death Is sald to
have occurred on the date stated above, at
m.
Duration
myocarditis 2 ..... mos
Paralysis Agitans
4 yrs.
Due to
Due to
3
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings :
Of operations
Date of
should be charged sta- tistically.
What test confirmed diagnosis? NO
20 Was disease or Injury In any way related to ocoupallon of deceased ?.
If so, spectty ................. Mahoney
(Signed)
.L ... Washington Ave.
6/18/ M. 04
(Address)
.Winthrop ...... lass .....
Date
19
Winthrop
43
22 NAME OF
FUNERAL DIREcmthrop. .... Mass.
ADDRESS
Received and filed
JUL. 1963
19
DATE FILED
(Registrar of city or town where death occurred)
June
23,
19
43
18 DATE OF
DEATH
June
18,
1943
5a If married, widowed per divorced MacNerven
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
#
8
AGE
Years
Months.
Days
if less than 1 day
Hours.
Minutes
Market Man (Retired)
Usual
9 Occupation :
Wholesale Market
Industry
10 or Business :
None
Il Social Security No ...
Nova Scotia
12 BIRTHPLACE (City)
(State or country)
John Jones
13 NAME OF
FATHER
Baddeck.
PARENTS
FATHER (City)
(State or country)
Isabella MacLilan
15 MAIDEN NAME
OF MOTHER
Baddeck,
Nova Scotia
16 BIRTHPLACE OF
MOTHER (City)
(State Egypter) E. Jones
Wife
17
Informant.
(Address)
124 River Rd. , Winthropy iMase
A TRUE COPY.r
ATTEST :
Reta Ml. Bishop
21 PLACE OF BURMALOP
CREMATION OR REMOVAL
(Ceme June 20,
(City or Town)
DATE OF BURIAL
Howard S. Reynolde
(Registrar of City or Town where deceased resided)
50m (e)-1-41-4667
Ceples s' hierher city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
14 BIRTHPLACE OF
Nova Scotia
Underline the cause to
which death
Of autopsy
Registered No. 1.29
(If U. S.
War Veteran,
specify WAR)
St.
71
R-302
1
PLACE OF DEATH
Suffolk (County)
Revere (City or Town) Hillside Rest Home
The Commonturalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
REVERE
(City or town making return)
Registered No.
130
(If death occurred in a hospital or institution,
{ give its NAME instead of street and number)
2 FULL NAME
Bridget Ryan (Kelleher)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
59 Winthrop
St.
Winthrop
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In hospital or institution.R.e.s.t .... Home
9
months
days.
years
(Before death)
(Specify whether)
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE|
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
18 DATE OF
DEATH
June
20, 1943
(Month)
(Day)
(Year)
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
MartinRyan
(Husband's name in full)
have occurred on the date stated above, at
II:30 A. .m. Duration (Unknown) ?.
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
8
80
AGE
Years.
Months.
... Days
If less than 1 day
Hours
.Minutes
Pernicious Anemia
2
yrs.
Usual
9 Occupation :
Own Home
Due to.
Il Social Security No ..
Boston
12 BIRTHPLACE (City)
(State or country)
Massachusetts
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings:
Of operations
Date of.
should be
charged sta- tistically.
What test confirmed dlagnosis ?.
20 Was disease or Injury in any way related to oooupation of deceased ?
If so, speolf;
C. T. Mahoney
(Signed)
(Address)
Winthrop,
Mass.
Date ..
6/20/M.
43
Foston
21 PLACE UP BURMABePh B,
CREMATION OR REMOVAL_
DATE OF BURIAL
John F. O Matey
22 NAME OF
FUNERAL DIRECTOEnthrop , Nass.
ADDRESS
Reoelved and filed.
19
(Registrar of City or Town where deceased resided)
50m (e)-1-41-4667
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Ireland
(State or country)
(Cannot be learned)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Margaret Ryan
Daughter
17
Informant.
(Address)
59 Winthrop St. , Winthropany
(City or Town)
19
A TRUE COPY.
Reta M. Bishop.
ATTEST :
( Registrar of city or town where death occurred)
DATE FILED
June 23,
19
43
19
HEREBY CERTI5
Y ,
That I attended deceased from
Jan. 1,
....
19
June
30
to.
June 18
43
19 death is said to
(Give maiden name of wife in full)
I last saw h
alive on
Arterio Sclerosis
2
yrs ..
Housewife
Industry
10 or Business :
None
13 NAME OF
FATHER
Michael Kelleher
Underline the cause to which death
Of autopsy
Ireland
1
No.
St.
(If U. S.
War Veteran,
specify WAR)
In this community 3
yrs. - mos :-
days.
PERSONAL AND STATISTICAL PARTICULARS
M R-301 ||
1 PLACE OF DEATH 8 Usual PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION Industry is very important. See instructions and extracts from the laws on back of certificate.
200m-10-'39. No. 8427-d
17 Michael Grace
Relation if any husband
Informant ..
(Address)
16 Neptune Rd., E. Boston
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial on transit permit was issued;
Www. D. Children
(Signature of Agent of Board of Health or other)
Health Ofrecer 6/ix/43
(Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
22
1943
(Year)
I HEREBY CERTIFY, That I attended deceased from
19
laufe 17
19 ..
9 cena 22
to.
19 ×3
last saw h ............ alive on,Y
22
19 43 death is said
to have occurred on the date stated above, at. 930A.m.
Duration
6 Age of husband or wife if alive.
7.9
.years
Immediate cause of death ..
ÅGE
79
.Years
Months.
.. Days
If less than 1 day
Hours
Minutos
9 Occupation:
Housewife
10 or Business:
At Home
1I Social Security No. none
St. John's
12 BIRTHPLACE (City)
(State or country)
Newfoundland
13 NAME OF
FATHER
John Crotty
14 BIRTHPLACE OF FATHER (City) (State or country)
Ireland
...
Of autopsy
What test confirmed diagnosis ?
PHYSICIAN Underline the cause to which death should be charged sta- tistically.
20 Was disease or Injury In any way related to occupation of deceased ?
If so, specify
(Signed)
M. D.
(Address) 19 Prunechest E.B
Date 6/22 19 ×3
21
Holy Cross, Malden
wn) Place of Burial, Cremation PERtrova25 . 1943 DATE OF BURIAL 19
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
Boston
Received and filed JUN 2 1 1943 19
A TRUE COPY ATTEST:
(Registrar)
information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
Suffolk (County)
BOSTON NOTIFIEO 7/9/43
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
$24
Registered No. .....
1
(If death occurred in a hospital or institution,
St.
give its NAME instead of street and number)
2 FULL NAME
annie
Grace
(If U. S.
specify WAR) no
(a) Residence.
No ..
(Usual place of abode)
16 Neptune Pdy
St.
Fast Boston Mass
Length of stay: In hospital or institution
Hosp.
years
months
5
days.
In this community
4 7yrs.
mos.
days.
(Specify whetber)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCEMarried
(write the word)
5a Ii married, widowed, or divorced
HUSBAND of
Mi chave raidGras & wife in full)
(or) WIFE of.
(Husband's name in full)
7 IF STILLBORN, enter that fact here.
Due to
Acuba Puluma adema
6/22/43
Due to
Chinees Myocarditis
Other conditions
...
Jangarea 51 Jell Handler
(Include pregnancy within 3 months of death)
6/17/83
Major findings :
Of operations
Sangue T Fall Hadder
Date of June 17.43
15 MAIDEN NAME
OF MOTHER
Johanna Ryan
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
Winthrop
(City or Town)
Winthrop Community Hospital
No ..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(If nonresident, give city or town and state)
(Month)
(Day)
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physleian 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, furnlsb for regis- tration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the discase of which be died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive hy 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 thercfrom 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 buman 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 be 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 de- livered to such board, agent or clerk, as the case may be, a satisfac- tory 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 bealth, or employed hy it or by the selectmen for the pur- pose, shall upon application make the certificate required of the at- tending physician. If death is caused by violenee, the medical exam- iner 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 a 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 bours 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 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 fur- nish 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, Seo. 45, G. L., (Tercentenary Edition.)
No undertaker or other person sball bury a buman body or the asbes thereof which have been brought into the commonwealth until he bas 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 Inter nent 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) Attonding 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 disabled 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) Modical 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 clectrical agents, and deaths following abortion, but also deaths from disease resulting from 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 Cause of Death .- Cause of death means the disease, or complication which causes death, not the mode of dying, e. g., beart failure, asphyxia, asthenia, etc. As principal cause name the disease causing death. As related causes, name earlier morbid 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 bad been given up or changed on account of the disease causing deatb, report the usual occupation prior to illness. If the deceased bad 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 bome 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 wbo bad no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
R-302
1
Norfolk (County) Milton (City or Town) PLACE OF DEATH No. 35 Winthrop
.....
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Milton
(City or town making return) 122
Registered No.
5
(If death occurred in a hospital or institution,
St. 1
give its NAME instead of street and number)
2 FULL NAME
Esther Task
(If deceased is a married, widowed or divorced woman, give also maiden name.)
33 Tewksbury
.St.
Winthrop Mass
(If nonresident, give city or town and state)
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(oz) WIFE of
Louis ..... Task
(Husband's name in full)
6 Age of husband or wife if alive.
.years
7 IF STILLBORNI, enter that fact here.
Years.
......... Months ............ Days
If less than I day
.. Hours
Minutes
Usual
9 Occupation:
Housewife
Industry
10 or Business:
Oym home
II Social Security No.
none
12 BIRTHPLACE (City)
(State or country)
Brooklyn, N. Y.
13 NAME OF
FATHER
Abraham Abrams
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Poland
15 MAIDEN NAME
OF MOTHER
Bertha Blond
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Germany
17 Louis Task
Relation, if any ( husband ...
Winthrop
A TRUE COPY.
ATTEST:
G. FRANK KEMP Franklam
(Registrar of city or town where death occurred)
DATE FILED
JUNE 22, 1943
19
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH.
June 22, 1943
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY. That I attended deceased from
June .... 18,
1943 .. , to ...... une .... 2.2.,
1943
I last saw h ......... alive on.
June 22,, 19 43, death is said
to have occurred on the date stated above, at
9:00 am
Immediate cause of death
Acute dilation of the heart
Duration
Due to
Chronic myocarditis
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Underline the cause to which death
Of autopsy
What test confirmed diagnosis ?
should be charged sta- tistically.
20 Was disease or Injury In any way related to occupation ol deceased ?
If so, spocify.
Samuel . Zundell
(Signed)
M. D.
(Address)
332 Blue Hill Aven
6/28/43
21 PLACE OF BURIAL,
CREMATION OR REMOVALKnights of Liberty
(Cemetery)
Montvalen)
DATE OF BURIAL
June 24, 1943
19
.....
22 NAME OF
FUNERAL DIRECTOR
Benjamin F. Solomon
ADDRESS
420Harvard St Brookline
Received and filed
JUN 2 - 1943
19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 5427-f after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) PARENTS
Watts da auf city of tomil mi which de ucceased resided as soon as possible 3 AGE63
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
.....
years
months
days.
In this community
yrs.
(If U. S.
War Veteran,
specify WAR)
no
white
73
Informant.
(Address)
33 Tewksbury St
Date of.
X
301 A
1
PLACE OF DEATH
Suffolk
(County) Winthrop
(City or Town)
No. 15 South Ave
The Commontoralth 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. 133
Registered No.
$ ( If death occurred in a hospital or institution,
give its NAME instead of street aud nuniber) St.
2 FULL NAME
Ellen M. Marlow Phelan
( If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 15 South Ave
(Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution
(Before death)
(Specify whether)
years
months
days.
In this community+
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
( write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
Sa If married, widowed, or divorced
HUSBAND of
Richard B! " Phelan full)
(or) WIFE of
( Husband's name in full)
6 Age of husband or wife if alive
years
IF STILLBORN. enter that fact here.
8
AGE
67 Years
Months Days
If less than 1 day
Hours.
Minutes
Usual
9 Occupation :
Housewife
Industry
10 or Business :
Own Home
11 Social Security No.
Woburn
12 BIRTHPLACE (City)
(State or country)
Mass
13 NAME OF
FATHER
Daniel Marlow
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
15 MAIDEN NAME
OF MOTHER
Bridget Hagan
16 BIRTHPLACE OF
MOTHER (City)
( State of country)
Ireland
17
Informant
(Address)
Mrs Charles Barry
Batighter
15 South Ave
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burlal or transit permit was Issued ? William B, Childuns (Signature of Agent of Board of Health or other)
agent June 26/43
(Omcial Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
26 1947
(Month)
(Day)
(Year)
18 | HEREBY CERTIFY, That I attended deceased from
215 1943 Ama 26 19 Ło .......
last saw h. W alive on.
Anh 25, 1942, death Is said to
have occurred on the date stated above, at LA
m.
Immediato cause of death ... metastatico Comma
Due to.
Due to
Other conditions
( Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of.
Of autopsy
What test confirmed diagnosis ?.
Underline the cause to which death should be charged sta- tistically.
20 Was disease or injury in any way related to occupation of deceased?
If so, spsolfy ..
(Signed)
(Address) 4 Link
the endate 6-26-196
, M. D.
21 Forest Glade Wakefield
Place of Burial, Creniation or Removal.
DATE OF BURIAL
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
Winthrop
Received and fled ..... JUM ... C.S ..... 1943
19
( Registrar)
100M-4 -2-42-8855
If deceased was & U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a reoital to that effect. PARENTS
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