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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