Town of Winthrop : Record of Deaths 1943, Part 82

Author: Winthrop (Mass.)
Publication date: 1943
Publisher:
Number of Pages: 594


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1943 > Part 82


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No undertaker or other person shall bury a human body or the ashea thereof which have been brought Into the commonwesith until he has re- ceived a permit so to do froor the hasrd of health or its sgent appointed to issue such permits, or if there is no such hoard, from the clerk of the town where the boily 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 internient is made .... Cbsp. 114. Sec. 46. G. L., (Tercentenary Edition).


Medical examiners shall mske examination upon the view of the dead hodies of only such persons ss sre supposed to have died by violence. If a medical examiner has notice that there is within his county the body of such a person, he shall forthwith go to the place where the body llea and take charge of the same; ... - General Laws, Chap. 38, Sec. 6.


RULES OF PRACTICE


The fulfillment of the purpose of these laws caiis for the observance of the following rules of practice :


(1) Attending physicians will certify to such deatha only as those of persons to whom they have given bedside care during a lsst illness from disease unrelated to any form of injury.


(2) Board of Health phyalolana wili 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 ahsent from home when the certificate of death is needed.


(3) Medloal Examiners will investigate and certify to all destha sup- posably due to Injury. These include not only deaths cansed directly or in- directly by traumatism (including resulting septicemla), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deatha from disease resulting from injury or infeotion 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 deatlı means the disease, or complication which causes death. not the moile of dying, e. g., heart failure, asphyxia, asthenia, etc. Aa principai cause name the disease caualng death. Aa related causes, name earlier morbid conditions, if auy, related to the principal cause and any important complication of the principal cause.


Statement of Occupation .- Precise statement of occupation la very 1m- portant, so that the relative healthfulnesa of various pursuits can he known, Make some entry in this section for every person aged 10 years or over. If the occupation had heen given up or changed on account of the discase causing desth, report the usual occupation prior to illness. If the deceased bsd retired from husinesa, report the usuai occupation prior to retirement. Children not gainfully employed may he returned as at school or at borne. For a woman wbose only occupatiou wss thst of home housework, write bousework. For s person engaged in domestic service for wages, however, designate the occupation hy the appropriate terma, aa housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.


SPACE FOR ADDITIONAL INFORMATION


RM R-302


1


SUFFOLK BOSTON


The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


BOSTON


(City or town making return) 239 9698


Registered No.


(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)


2 FULL NAME


Horace Stanley Gilchrist


(If deceased is a married, widowed or divorced woman, give also maiden name.)


45 Hermon


St.


Winthrop,


Mass.


(If nonresident, give city or town and State)


Length of stay: In hospital or Institution.


(Before death)


(Specify whether)


years


months


4


days.


In this community


yrs.


mos.


4


days.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


M


4 COLOR OR RACE


5 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCEDarried


5a If married, widowed, or divorced de M. Henderson


HUSBAND of


(or) WIFE of


(Husband's name in full)


6 Age of husband or wife if alive


62


years


7 IF STILLBORN, enter that fact here.


AGE


72


Years


8


Months


27


Days


If less than 1 day


Hours ..


Minutes


Usual


9 Occupation :


Laundry .... salesman


Industry


Family laundry


10 or Business :


Il Social Security No ...... no.ne ..


12 BIRTHPLACE (City)


(State or country)


Canada


13 NAME OF


FATHER


Samuel Gilchrist


PARENTS


14 BIRTHPLACE OF


FATHER (City)


(State or country)


Canada


15 MAIDEN NAME


OF MOTHER


Elizabeth Belyea


16 BIRTHPLACE OF


MOTHER (City)


(State or country)


Canada


17 Informant (Address)


Relation, if any .w.1.1 ......


A TRUE COPY.


ATTEST:


Francis


DATE FILED


(Registrar of city or town/where death occurred)


Oct. 28


43


19


......


18 DATE OF


DEATH


October


2/1


(Month)


(Day)


(Year)


19 | HEREBY CERTIFY,


That ! attended deceased from


October 20, 1913


to October 21


191.3


I last saw him


.. alive on


October 24, 19 Li death Is said to


have occurred on the date stated above, at.


10.50 Pm.


Duration


Immediate cause of death.


Concestive failure


Term.


Due to.


Aortic bacterial endo-


mo.s.


carditis


Due to.


Other conditions


(Include pregnancy within 3 months of death)


Physician


Major findings :


Of operations.


Date of


Underline the cause to which death should be charged sta- tistically.


Of autopsy


What test confirmed diagnosis?


autopsy


20 Was disease or Injury in any way related to occupation of deceased ?


no


If so, specify


H. W. Benjamin


(Signed)


M. D.


(AddressP ................... Hos.n.


Data 0-25 1943


21 PLACE OF BURIAL,


winthrop-Winthrop, Mass.


CREMATION OR REMOVAL


(Cemetery )


(City or Town).


DATE OF BURIAL


October 27


19 113


22 NAME OF


FUNERAL DIRECTOR


H. S. Reynolds


ADDRESS


winthrop, Mass.


Received and filed


NOV-1-0-1942


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.) resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased


1


PLACE OF DEATH


(City or Town)


No. Peter Bent Brigham Hospital


(If U. S.


War Veteran,


specify WAR)


(a) Residence. No.


(Usual place of abode)


1943


(Give maiden name of wife in full)


RM R-302


1


PLACE OF DEATH


SUFFOLK BOUTON


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.


9674


(If death occurred in a hospital or institution,


St.


¿ give its NAME instead of street and number)


2 FULL NAME


Donald wilson


(If deceased is a married, widowed or divorced woman, give also maiden name.)


173 River Road


St.


Winthrop,


Mass.


(If nonresident, give city or town and State)


Length of stay : in hospital or institution.


(Before death)


(Specify whether)


years


months


2


days.


in this community


yrs.


mos.


2


days.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


M


4 COLOR OR RACE| 5 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED


Single


(Month)


(Day)


(Year)


19 | HEREBY CERTIFY,


October 22 1943


to Uct 24/13


19


im


Oct .


death Is said to


have occurred on the date stated above, at.


12.36 a . m.


Duration


Immediate cause of death


MeningitisMeningococcic


1 .... week


Due to.


Due to.


Other conditions.


splanchnic toxemia


(Include pregnancy within 3 months of death)


Major findings :


Of operations


Physician Underline the cause to which death


Of autopsy


as above


What test confirmed diagnosis ?.


.....


autopsy


20 Was disease or Injury In any way related to oooupation of deceased ?


(Signed).


M. D.


(Address) Mass, Nem. Hosp


Dato.


10-2/19 43


nass.


21 PLACE OF BURIAL, Holy Cross-Malden,


CREMATION OR REMOVAL.


(Cemetery)


ity or Town)


DATE OF BURIAL


October 26/113


19


22 NAME OF


FUNERAL DIRECTOR


R. C. Kirby


ADDRESS


Boston, Nass.


Reoelved and filed


NUV IC 191:


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.) resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased


PARENTS


14 BIRTHPLACE OF


FATHER (City)


(State or country)


Nova Scotia


15 MAIDEN NAME


OF MOTHER


Mary E. Silva


16 BIRTHPLACE OF


MOTHER (City)


(State or country)


Boston, Mass.


17


Informant


(Address)


Relation, if any (Hother


A TRUE COPY.


Tay


ATTEST :


(Registrar of city or town where death occurred)


DATE FILED


October 27


1943


18 DATE OF


DEATH


October


24


1943


5a If married, widowed, or divorced


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


6


.Years


AGE


2


Months.


.Days


If less than 1 day


.Hours.


.Minutes


Usual


9 Occupation :


-


Industry


10 or Business :


Il Social Security No.


12 BIRTHPLACE (City)


(State or country)


East Boston, mass.


13 NAME OF


FATHER


Joseph Wilson


Date of.


should be charged sta- tistically.


If so, speoify


H. M. Pollock


That i attended deoeased from


i last saw h


alive on


24/43 19


(If U. S.


War Veteran,


specify WAR)


(a) Residenoe. No.


(Usual place of abode)


(City or Town)


No.


Mass. Memorial Hospitals


M R-302


1


PLACE OF DEATH


FFOLK BOSTON


(City or Town)


Carney Hospital


The Commontucalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


ROSTON


(City or town making return)


Registered No.


9862


(If death occurred in a hospital or institution, St. give its NAME instead of street and number)


Louise Hogan


2 FULL NAME


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residenoe. No.


(Usual place of abode)


82 Waldemar Ave.


St.


Winthrop, Mass.


Length of stay: In hospital or institution


(Before death)


(Specify whether)


years


months


10 days.


In this community


yrs.


mos.


10 days.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


18 DATE OF


DEATH


October


31


(Month)


(Day)


(Year)


19 | HEREBY CERTIFY,


Oct. 22/43


19


That I attended


deceased from


I last saw h .............. alive on.


Oct. 31/43


19


., death Is said to


have occurred on the date stated above, at.


1.4.5


.& ... m.


Duration


Immediate oause of death


Uremia


4 days


Due to.


Carcinoma of uterus


with metastasis


? mos


Due to.


Other conditions.


(Include pregnancy within 3 months of death)


Major findings :


Of operations


Date of


should be charged sta- tistically.


What test confirmed diagnosis?


20 Was disease or Injury in any way related to oooupatlon of deceased ?.... n.Q. If so, specify


(Signed)


S ...... R ...... Baker


M. D.


(Address)


Carney Hospital


Date.


10-31


1943


21 PLACE OF BURIAL,


Holy Cross Cem-Malcen, Mass.


DATE OF BURIAL


22 NAME OF


FUNERAL DIRECTOR


J. F. O'Maley


ADDRESS


Winthrop .... Mass.


Reoelved and filed.


NOV 101912


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.) resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased


PARENTS


14 BIRTHPLACE OF


FATHER (City)


(State or country)


Ireland


15 MAIDEN NAME


OF MOTHER


Catherine McLoughlin


16 BIRTHPLACE OF


MOTHER (City)


(State or country)


Ireland


17 John Hogan


Relation, If any .... son


Informant


(Address)


A TRUE COPY.


ATTEST :


(Registrar of city or town where death occurred)


DATE FILED


Nov. 3/43


19


5 SINGLE


(write the word)


Widowed


MARRIED


WIDOWED


or DIVORCED


5a If married, widowed, or divorced HUSBAND of


(or) WIFE of


John W(Give gaiden name of wife in full)


(Husband's name in full)


6 Age of husband or wife if alive years


7 IF STILLBORN, enter that fact here.


AGE.79 .. Years. Months. Days


If less than 1 day Hours .Minutes


Usual


9 Occupation :


Housewife


Industry


10 or Business :


own home


Il Social Security No.


--


12 BIRTHPLACE (City)


(State or country)


Cambridge, Mass.


13 NAME OF


FATHER


Peter Kivlan


Physician Underline the cause to which death


Of autopsy.


CREMATION OR REMOVAL


19


(Cemetery Nov. 2/43 City or Town)


(If U. S.


War Veteran,


specify WAR)


1943


3 SEX


F


4 COLOR OR RACEJ


W


No.


(If nonresident, give city or town and State)


to


Oct. 31/43


19


RM R-301 !


Suffolk


(County)


Winthrop


-


1


PLACE OF DEATH


2 FULL NAME.


(a) Residence.


No.


(Usual place of abode)


Length of stay : In hospital or institution


(Specify whether)


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


White


male


5 SINGLE


marcel


MARRIED


WIDOWED


or DIVORCED


Sa If married widowed, or forcegreat


HUSBAND of YEARS


(Give maiden name of wife in fully


(or) WIFE of.


(Husband's name in full)


6 Age of husband or wife if alive.


-82 -


7 IF STILLBORN, enter that fact here.


8


81


Years


7


Months


16 Days


If less than 1 day


AGE


Hours.


Usual


9 Occupation:


Retired


II Social Security No.


×


12 BIRTHPLACE (City)


(State or country)


3 NAM!


FATHER


Or Jonathan . M. Tucker


14 BIRTHPLACE OF Salisbury


FATHER (City)


(State or country)


mass


15 MAIDEN NAME


OF MOTHER


Sarah. S. Hewitt


PARENTS


16 BIRTHPLACE OF


MOTHER (City)


Boston Mais


(State or country)


Informant


........


information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state


200m-10-'39. No. 8427-d


N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of


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


Industry


Carrega Y automobile M/9


10 or Business:


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Www. D. Childrenis


(Signature of Agent of Board of Itealth or other) Health Officer 11/3/43 (Official Designation) (Date of Issue of Hermit)


MEDICAL CERTIFICATE OF DEATH


18 DATE OF


DEATH


(Month)


(Day)


1


1943


( Year)


19 I HEREBY CERTIFY. That I attended deceased from


Schwa Tucker


Get 24


1943, to.


200. 1


1943


I last saw him alive on ..


Oct 31


19 ...... , death is said


to have occurred on the date stated above, at.


550Mm.


Duration


.years


Immediate cause of death ..


Cerebral Hemmorrhage


7 days .........


Due to


Senile Arteriosclerosis


10years


Due to .............. ......


Other conditions


(Include pregnancy within 3 months of death)


Major findings :


Of operations


Date of ..


.....


Of autopsy


What test confirmed diagnosis ?


Clinical Signs


...


PHYSICIAN Underline the cause to which death should be charged sta- tistically.


20 Was disease or lojory lo any way related to occupation of deceased ?


If so, specify ..


(Signed)


(Address)


Winthrop


Date 1/02/ 1943


21 Winches Cemetry


Writing mais Place of Burial, Cremation or Removal. (City y Town) DATE OF BURIAL .19 .. J


22 NAME OF


Chus. R. Benacción


ADDRESS


Received and fited.


1943


19


A TRUE COPY ATTEST:


(Registrar)


..


days.


(If nonresident, give city or town and state)


In this community 62 yrs.


mos.


days.


...


years


months


The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


(City or town making return)


Registered No.


1


(If death occurred in a hospital or institution,


St. l


give its NAME instead of street and number)


Frank-Willard-Tucker


(H U. s.


War Veteran.


specify WAR)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


46 Brookfield Road Winther Maso


(write the word)


Minutes


17 Jennie & Tucker Relation, if any (Address) 46- Dworfield Road Winlang


M. D.


FUNERAL DIRECTOR


(City or Town) Winthrof Community- Hospital No


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 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 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 health or its agent appointed to issue such permits, or if there is no such board. from the clerk of the town where the person died ; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body Is buried. No such permit shall be issued until there shall have been 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 health, or employed by 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 violence, 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 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 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 eause of death shail 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, 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 perinits, 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, Seo. 46, G. L., (Tercontenary 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 carc 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 disease 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 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., heart fallure, 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 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


R-303-A


1


PLACE OF DEATH


Jul/Mc (County) .... Winthrop. (City or Town) 299 A Shirley 57


The Commauturalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH


To be filed for burial permit with Board of Health or its Agent.


Registered No.


243


St. § (If death occurred in a hospital or institution, I give its NAME instead of street and number) 7


2 FULL NAME


Burstein


(If deceased is a married, widowed or divorced woman, give also maiden, name.)


(a) Residence,


No.


44 Hawthorne are Ponctuel


(Usual place of abode)


Length of stay: In hospital or Institution.


(Before death)


(Specify whether)


years


months


days.


In this community 22 yrs.


mog.


days.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


.3 SEX


Female


4 COLOR OR RACE|


White


5 SINGLE


(write the word)


MARRIED


WIDOWED married


or DIVORCED


5a If married, widowed, or divoroed


HUSBAND of


Jan Give maiden name of with in full een


(or) WIFE of


(Husband's name in full)


6 Age of husband or wife If alive 64


years


7 IF STILLBORN, enter that fact here.


8


AGE.


64 Years


Months.


Days


If less than 1 day


.Hours .........


.Minutes


Usual


9 Occupation :


Housewife


Industry


at home


11 Social Security No mone


12 BIRTHPLACE (City)


Quasia


(State or country)


13 NAME OF


FATHER


Elizer Kaplan


PARENTS


14 BIRTHPLACE OF


FATHER (City)


Russia


......


(State or country)


15 MAIDEN NAME


OF MOTHER


South Sarah be learned)


16 BIRTHPLACE OF


MOTHER (City)


(State or country)


Russia


19.7


17


Informant Jack Burger


Relation, if any


DATE OF BURIAL


november 3


43


( Address). 4) Coolidge It Brooklin


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued. 3.120


(Signature of Agent of Board of Health of other) 11/5/4


(Official Designation) (Date of Issue of Permit)


18 DATE OF


DEATH


Jusember -2 -1943


(Month)


(Day)


(Year)


19 | HEREBY CERTIFY that I have Investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.) Corman ) cheroses myocarditis


20 Aooldent, sulolde, or homlolde (specify)


Date of poourrenoo.


19


Where did Injury occur ?


(City or town and State)


Did Injury ocour In or about home, on farm, In Industrial place, or In publio


place ?


(Specify type of place)


Manner of


Collapsed white shopping t


Injury


Nature of


Carrying parcel


Injury


While at work?


O Was there an autopsy ?.


21 Was disease or Injury In any way related to occupation of deceased ?


If so, speolfy.


M. D.


(Address)


Date-2-1943


22


Winthrop Cem. Everest


Place of Burial, Cremation or Removal.


(City or Town)


3 NAME


Manuel Stanetaky


ADDRESS


Washington It. Dor


Reoelved and filed


NOV 8 1942


.19


(Registrar) X


=


5


cannot (Signed)


50m (g)-1-41-4667


If deceased was a U. S. War Veteran, G. L. Chap. 46, Seotion 10, requires physiolans to Insert a recital to that effeot




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