USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1947 > Part 23
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Medical examiners shall make examination upon the view of the dead bodies of only such persons as are 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 lies and take charge of the same; .. . - General Laws, Chap. 38, Sec. 6.
No undertaker or other person shall bury a human body or the ashes 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 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) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose phy- sician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup- posably 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, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause.
Statement of Occupation .- Precise statement of occupation is very im- portant, 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, how- ever, 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-301 A 1
Nguenfull
1
PLACE OF DEATH
Suffolk (County) "BostonWinthrop
(City or Town)
No.
30 Sewall Ave
The Commonwealth 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.
65
Registered No. § (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Henry Hirshberg
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
30 Sewall Ave.
St
Winthro
Mass
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution
( Before death)
( Specify whether) a
years
months
days.
In this community
15 yra.
mos.
dayı.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Nale
4 COLOR OR RACE
White
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Married
5a If married, widowed, or divorced
HUSBAND of
Gertrude .... Wasserman
(Give maiden name of wife in full)
( or) WIFE of
( Husband's name In full)
6 Age of husband or wife if allva
46
yaars
7 IF STILLBORN, enter that fact here.
8
AGE 5.2. Years
Months
Days
If less than 1 day
Hours
Minutes
Usual
9 Occupetion :
Funiture Dealer
Industry
10 or Business :
For Himself
11 Social Security No.
None
12 BIRTHPLACE (City)
( Siste or country)
Boston. Mass,
13 NAME OF
FATHER
Lovis Hirshberg
14 BIRTHPLACE OF
FATHER (Clty)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Esther Levenson
16 BIRTHPLACE OF
MOTHER (City)
(State or country )
Russia
17
Informant illiam Kopans
257 South St. So Prostline
Reiation, Brother.
I HEREBY CERTIFY that a satisfactory standard oertifloats of death was Aled why Dy BEFORE thebariat of transit parmit was Issued : Water A. lakersx
(Signature of Arout of Board of Health or other) Health Officer 3/3/147
( Date of Inque of Dermit)
18 DATE OF
DEATH
March
30
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY.
Thet I attended deosased from
March 30, 19:17, to
Marcha 30
19.16 7
I last saw him alive on.
3-30-47, 19
..... death Is said to
heve occurred on tha data stated above, at
11:30 Am.
Immediate oouse of death ...
IMPORTANT
9 hours
Due to
Due to.
Other conditions
( Include pregnancy within 3 months of death)
Mejor findings:
Of operations
Data of
Of outopsy
What test confirmed diagnosis?
IMPORTANT Physician Underline the cause to which death should be charged sta. tistically .
20 Was disease or injury in any way ralatad to oooupation of deceesed ?.... Y.
If so, spaolfy.
('Signed)
. M. D.
(Address) 147 Aleney St WuerAvec Date 3-301947
21 Meretzer
Place of Burial, Cremation or Removai.
Woburn, Mass.
(City or Town)
...
W PATE OF BURIAL
March
.31,
19.47
22 NAME OF
Benjamin Birnbach
FUNERAL DIRECTOR
ADDRESS
.10. Washington St. ,Dorchester
Received and Aled APR - 3 1947 19
( Registrar)
terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and
extracts from the laws on back of certificate.
If deceased was a U. S. War Veteran, Q. L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
Jurisdiction declined ly medical examiner
PARENTS
100m.(R)-1-45-15510
Yomelal Designation)
PHYSICIAN - IMPORTANT
( Was deceased a
U. S. War Veteran,
No
if so specify WAR).
(Usual place of abode)
1947
Duration
.....
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 re- quired 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.
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, speci- fying the war, and shall also certify in such certificate both the primary and the secondary or immediate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer shall forfeit ten dollars. For the purposes of this sec- tion and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relicf expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nine- teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
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 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 insufficient, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate re- quired of the attending physician. If death is caused by violence, the medi- cal 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 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 furnish for registration any other neces- sary 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).
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are 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 lies and take charge of the same; ... - General Laws, Chap. 38, Sec. 6.
No undertaker or other person shall bury a human body or the ashes 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 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) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose phy- sician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup- posably 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, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause.
Statement of Occupation .- Precise statement of occupation is very im- portant, 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, how- ever, 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
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ORM R-305
Middlesex
(County)
1
Malden
(City or Town)
No. 27 Cedar
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Mal den (City or town making return)
Registered No.
66
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Arthur H. Harper
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
18 James Ave .
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.
4
1
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Marbh)16, 1947y)
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.)
! !
Found dead
Arteriosclerotic heart
disease
20 Accident, suicide, or homicide (specify) ....... no.
Date of occurrence
19
Where did Injury occur ?
(City or town and State)
Did injury occur in or about the home, on farm, In Industrial place, or In publio place?
(Specify type of place)
Manner of
Injury
Nature of Injury
While at work?
Was there an autopsy?
21 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
Andrew D. Guthrie
M. D.
(Address)
408 -Salem St. Medford 3/16/47
22
verside
Place of Tomar,
HOR or Removal.
Sayous
Relation, if any DATE OF BURIAL March 18, 1947 19
23 NAME OF
FUNERAL DIRECTOR
M.A.Cowän & Son
Malden
19
(Registrar of City or Town where deceased resided)
V urLeanru icalticu)
=
=
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD Industry 10 or Business :
25m (h)-1-41-4667
17 Informant (Address)
Alice Beetle
Sister
winthrop
DATE FILER Mar.
25, 1947
1
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
widowed
HUSBAND of
(Give maidgo ymelof wife /hnite
(Husband's name in full)
6 Age of husband or wife if alive years
If less than 1 day Hours. Minutes
Retired
Real Estate & Insurance
England
Henry W. Harper
England
Emma Fowler
England
A TRUE COPYL 8
ATTEST :
(Registrar of city or town where death occurred)
19
2 FULL NAME (Usual place of abode) 3 SEX 4 COLOR OR RACE that married, widowed, or divorced (or) WIFE of 7 IF STILLBORN, enter that fact here. 8 AGE Years Months. Days B 13 9 Occupation : 11 Social Security No. 12 BIRTHPLACE (City) (State or country) London 13 NAME OF FATHER 14 BIRTHPLACE OF FATHER (City) 15 MAIDEN NAME OF MOTHER 16 BIRTHPLACE OF PARENTS MOTHER (City) (State or country) occurred. (See Chap. 46, Sec. 12, G. L.) of the city or town in which the deccascd resided as soon as possible after the close of the month in which the death resided in another city or town at the time of death should be made forthwith and transmitted on Form R.305 to the clerk (State or country) London
PLACE OF DEATH
St.
(If U. S.
War Veteran,
specify WAR)
Wint hrop
(Year)
ADDRESS
Received and filed.
APR 16 1947
RECEIVED
TOWN CL 11 12 1
10
00
5
6
APR 161947 PM
RM R-302
91 PUOLE
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
St.
(If death occurred in a hospital or institution,
give its NAME instead of atreet and number)
2 FULL NAME
David Lurensky
(If deceased is a married, widowed or divorced woman, give also maiden name.)
15 Coral Ave
(a) Residenoe. No.
(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
2
months
1
da y s.
In this community
yrs.
2
mos.
1
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
4 COLOR OR RACE
W
5 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
Jan 20
19.
4%
to
That J attended deocased from
Mar 21
19.
47
I last saw him
alive on
Mar 21
19.47
death is sald to
have occurred on the date stated above, at
4.30 A
m.
Duration
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that faot here.
8
50
AGE
Years
10
.Months.
6 :
Days
If less than 1 day
Hours.
Minutes
Usual
9 Ocoupation :
Meat Cutter
Industry
10 or Business:
M. Blinder
11 Soolal Seourity No ......
Unknown.
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Eli Lurensky
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17
Informant ....
Hospital ... Records ..... V.A.H(
Reiation, if any (Address)
A TRUE COPY.
ATTEST :
(Registrar of city or town where death occurred)
DATE FILED
Mar 25, 1947
19
22 NAME OF
FUNERAL DIRECTOR
B. Birnbach
ADDRESS
Boston
Received and filled
APR 22 19.4 /
19
(Registrar of City or Town where deceased resided)
50m.(b)-6.44-14607
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.802 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
PLACE OF DEATH
1 (County)
1
(City or Town)
No.
Veterans Administration Hosp
Boston
(City or town making return)
Registered No.
266462
(If U. S.
War Veteran,
WW I
spoolfy WAR)
-
Winthrop,
Mass
5a If married, widowed, or divorced Beatrice Cohen
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
45
Immediate cause of death Primary Amyloidosis of the liver
? spleen,
? heart
6 mos
Due to.
Due to.
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings : Paracentesis : 1-29 & 3-12-47 Of operations
Underline the cause to which death
Thoracentesis
Date of.
1-27;3-3;
3-6-47
should be charged sta-
Of autopsy
none
What test confirmed diagnosislaboratory ; clinice istically. 20 Was disease or Injury In any way related to occupation of deceased?
If so, spoolfy
(Signed)
J.
Poutas
M. D.
(Address)
Boston
Date
.. 3-2119.47 ..
21 PLACE OF BURIAL,
Kenneseth Israel Cem
CREMATION OR REMOVAL
(Cemetery woburn, &sor Town)
DATE OF BURIAL
Mar 23 1947
19
18 DATE OF
DEATH
Mar 21, 1947
--
RECEIVED
1.
51
APR221947 FM
Ent : 4-18-18
Disc: 9-30-21 Honorable
Rank: Ship's Cook 3/c Org : USN No : 1822188
RM R-302
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 returne of deaths recorded during the previous month which occurred in your city or town in case the deceased
PLACE OF DEATH
Suffolk (County)
1
Boston
(City or Town)
No.
Infant's 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.
68 3144
(If death occurred in a hospital or institution, St.
give its NAME instead of street and number)
Lee Mark Berman
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
89 Crest Ave.
St.
(If nonresident, give city or town and State)
Length of stay: In hospital or institution ..
(Before death)
(Specify whether)
years
months 20 days-
In this community
yrs.
mos. 20 days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX M
4 COLOR OR RACEI
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single
5a If married, widowed, or divoroed HUSBAND of
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife If allve
years
7 IF STILLBORN, enter that faot here.
8
AGE.
Years
21
Months.
Days
if less than 1 day
Hours.
.. Minutes
Usual
9 Ocoupation :
-
industry 10 or Business:
11 Soolai Security No.
12 BIRTHPLACE (City)
(State or country)
Winthrop Mass,
13 NAME OF
FATHER
David Berman
14 BIRTHPLACE OF
New York N.Y.
15 MAIDEN NAME
OF MOTHER
Estelle White
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston Mass.
17 informant. (Address)
Dr ..... Bernar RelatioFather
A TRUE COPY
ming
ATTEST :
(Registrar of city of town where death occurred)
DATE FILED
April 8
19 47
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
April 4/47
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
March 15
19
47 to
April 4
19
47
I last saw h ..
im alive on.
April 4 , 19 47 death is said to
have occurred on the date stated above, at.
11:07AM
m.
immediate cause .of death
Pneumonia secondary to aspiration
Duration .6 ... Hrs"
Due to
Due to.
Other conditions.
Prematurity
(Include pregnancy within 3 months of death)
Major findings :
Of operations
None
Date of
should be
Of autopsy .
.Spotty .... pulm atelectasis
What test confirmed diagnosis ?.
Autopsy.
20 Was disease or injury In any way related to occupation of deceased ?.
if so, speolfy
No
(Signed)
Jerome S Beloff
(Address)
300 Longwood Ave . Date
4-5, 47
M.
21 PLACE OF BURIAL,
Mt. Lebannon Agudath Israel
CREMATION OR REMOVAL
(Cemetery)
West Roxbury
DATE OF BURIAL
Apr11 6/47
19
22 NAME OF
FUNERAL DIRECTOR
B Birnbach
ADDRESS
Dorchester Mass.
Reoelved and filed
APR 22 1947
19
(Registrar of City or Town where deceased resided)
1
Underline the cause to which death
charged sta-
tistically.
FATHER (City)
(State or country)
PARENTS
50m.(b) -6-44.14607
(if U. S.
War Veteran,
specify WAR)
Winthrop
Mass.
(Usual place of abode)
(Give maiden name of wife in full)
That i attended deceased from
Physician
RECEIVED
.1,2
1
6
APR221947 PM
R-301 A +
1
No.
2 FULL NAME
3 SEX
Male
(or) WIFE of
8 .61
AGE
Years
Industry
10 or Business:
PARENTS
If deceased was a U. S. War Veteran, Q. L. Chap. 46, Seotion 10, requires physiolans to insert a recital to that offoot.
extracts from the laws on back of certificate.
should be carefully supplied. Aut should be stated EARGILT. PHYSICIANS should stare CAUSE Of DEATH in plain
( Siste or country)
terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and
4 COLOR OR RACE1
White
5 SINGLE
( write the word)
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed, or divorced herine Pragge
HUSBAND of
(Give maiden name of wife in full)
( Husband's name In full)
6 Age of husbend or wife if allva 55
yaors
7 IF STILLBORN, enter that fact hera.
2
Months
15 Days
If less than 1 day
Hours
Minutas
Usual
9 Occupation :
Shipper
Hardware
11 Social Security No.
029- 10-3954
12 BIRTHPLACE {City)
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