USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1948 > Part 29
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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 suchi 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 wben 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
so that it may be properly classified under the International Classification of Causes of Death. See reverse side for If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a recital to that effect extracts from the laws relative to the return of certificates of death.
1
PLACE OF DEATH
Salfolk County) Wuntherole (City or Town) Registered No. 4) Bellevue Outve. No. St. § ( If death occurred in a hospital or institution, I give its NAME instead of street and number)
To be filed for burial permit with Board of Health or Its Agent.
28
PHYSICIAN-IMPORTANT (Was deceased a U. S. War Veteran, If so speolfy WAR)
(a) Residenoo. No.
47 Bellevue Stor Nuthrush.
(Usual place of abode)
Length of stay : In hospital or Institution.
(Before death)
( Specify whether)
years months days.
(If nonresident, give city or town and State)
In this community 30 yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Male
4 COLOR OR RACE
White
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Widowed
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Maude S Scott
(or) WIFE of
(Husband'a name in full)
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that fact here.
8 68
AGE
11
Years
.Months
27 Days
If less than 1 day
Hours
.Minutes
Usual
9 Occupation :
Superintendent
Industry
Gas & Light Co.
10 or Business :
11 Social Security No ...
023-10-6991
East Boston
12 BIRTHPLACE (City)
(State or country)
Nass.
13 NAME OF
FATHER
Leavitt Palmer
14 BIRTHPLACE OF
FATHER (City)
Hingham
(State or country)
Mass.
15 MAIDEN NAME
OF MOTHER
Unable to obtain
16 BIRTHPLACE OF
MOTHER (City)
Hingham
(State or country)
Mass,
17 Willis Johnson
Nephew if any
Informant
( Address)
47 Bellevue Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial of transit permit was Issued :
ignature of Agent of Board of Health' or other)
4/29/48
7 (Official Designation) (Date of Issue of Permity
18 DATE OF
DEATH
(Month)
april - 37-1948
(Day)
(Year)
19 | HEREBY CERTIFY that I have Investigated the death of the person above-named and that the CAUSE AND MANNER thereof ara as follows: (If an injury was involved, state fully.) Cancer f. heck Pathological Fractures / cervical fertilia. asterio Scheritis Heart Viccese
20 Accident, sulolde, or homlolde (specify)
Date of ooourrenoe,
19
Where did Injury .ooour?
(City or town and State)
Did Injury ooour In or about 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 deoeased ?
If so, spoolfy
Buckley
(Signed)
M. D.
(Address)
Basta
Hingham
22
Hingham
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL ...
April
30
1948
23 NAME OF
FUNERAL DIRECTOR
Kawoud S Janolde
ADDRESS
immunis mars
Received and filed.
19
MAY 3 1948
(Registrar)
50m-(f)-6.43.12056
2 FULL NAME Louis
Louis L. Palmer
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Uffe Vanmantraith uf Ellassachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
PARENTS
MEDICAL CERTIFICATE OF DEATH
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 s person whom he has sttended 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 deatlı, 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 sume was contracted, the duration of his last illness, when last seen alive by the physiciau or officer and the date of his death ... Gen. Laws, Chap. 16, 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, invert 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 Bec- tion and of sections forty-five, forty-six and forty-seven of said chapter one hunilred and fourteen, the word "war" shall inchide the China relief ex- pedition and the l'hilippine 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, sud the Mexi- can border service of nineteen hundred and sixteen and niueteen 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 perinit froin the board of health, or ita 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 ita agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued untii 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 ss hereinafter provided. If there is no attending physician, or if, for sufficient ressons, his certificate caunot 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 attemling physician. If desth is caused by violence, the medical examiner shall make such certificate. If auch a permit for the removal of a human body, not previously interred, from one town to an- other within the coninionwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the pos- session of the undertaker desiring to inake such renioval ahall 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 re- moval, 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-xix, that the deceased served in the army. navy or marine corps of the United States in sny 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 regis- tration. The person to whom the permit is so given and the physician cer tifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may re- quire .- 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 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 funersi is to be held, or from a per- son sppointed to have the care of the cemetery or burial ground in which the interuncut is made. ... Chap. 114, Sec. 46, G. L., (Terceutenary Edi- tion).
Medical examincra shall mske exsmiustion upon the view of the dead bodies of only auch persons as are supposed to liave died by violence. If a medical examiner has notice that there ia 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 sanie; ... - General Laws, Chap. 3S, Sec. 6.
... He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residence, if known; otherwise a description as full as may be, with the cause and manuer of death .- General Laws, Chap. 33, Sec. 7.
. The medical examiner certifies the cause and manner of death to the best of his knowledge and belief.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calla for the obaervance of the following rules of practice :
(1) Attending physioiana will certify to such deaths only as those of persona to whom they have given bedside care during a last illnesa from disease unrelated to any forin of injury.
(2) Board of Health physiolans will certify to ruch deaths only as those of persona who, though disabled by recognized disease uurelated to any form of injury, have died without recent medical attendance or whose physi- cian 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 deatha caused directly or in- directly by trauinatism (including resulting septicemia), and by the action of chemical (druga or poisona), 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 persona not disabled by recognized disease, and those of persons found daad.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will atate the cause and manner thereof, and will specify : (1) Under cause, the nature of an injury and of its consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Com- pound fracture of the femur with ensuing septicemia (gas baciilus) caused by a steam railway accident." "Pistol shot wound of the chest with asso- ciated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether adininistered as a aurgical anaesthetic." "Fracture of the skull with associated internal injury sus- tained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause its known or presumahle nature; anıl (2) uinler manner, indicate the circum- stances leading to medico-legal inquiry. For example : "Hemorrhage spon- taneous of the brain (basal ganglia) ( found dead in bed)." "Ileart disease, presuinably coronary sclerosis. (Sudden death. )"
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have met his death by violence, until a permit, signed by the Medical Examiner, has first been obtained .- General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
M R-302
1
PLACE OF DEATH
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)
4032)
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
Anna McCulley
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(If U. S.
War Veteran,
specify WAR)
1
(a) Residenos. No.
(Usual place of abode)
46 Winthrop
St.
Winthrop
Mass
(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 35
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX Female
4 COLOR OR RACE|
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
April 28, 1948
(Month)
(Day)
(Year)
5a If married, widowed, or divoroed HUSBAND of
(or) WIFE of
Robert Mcculley
in full)
(Husband's name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that faot here.
8 56
AGE
Years
11
Months
.. Days
If less than 1 day
Hours
Minutes
Usuai
9 Ocoupation :
Housewife
Industry 10 or Business :
11 Sooiai Security No ..
12 BIRTHPLACE (City)
(State or country)
Pa
13 NAME OF
FATHER
James Gaynor
PARENTS
14 BIRTHPLACE OF
Phila
FATHER (City)
(State or country)
Pa
15 MAIDEN NAME
OF MOTHER
Annie Coyle
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Pa
Phila
17 informant (Address)
Mrs. Anna DiLorenzo. Relation, if any "dau 46 Winthrop St Winthrop
A TRUE COP
ATTEST :
Michael Milanning
(Registraz of city of town where death occurred
DATE FILED May 3 1948
19
I HEREBY CER
'Apr 27 EgFr .
19
to
Apr 28
19
I last saw h ............ alive on
Apr 28, 19.48 death is said to
have ocourred on the date stated above, at. .1: 08.A m.
Duration
Immediate cause of death. Congestive heart failure
1 day
Due to Coronary thrombosis
2 days
Other conditionsAcute Castro-duodenitis !! Mabetes melli months of death)
Physician
Underline the cause to
Major findings: None Of operations
Date of
should be charged sta- tistically.
What test confirmed diagnosis ?.
Autopsy
20 Was disease or injury in any way related to oooupation of deceased ?
If so, specify.
W T S Thorndike
(Signed)
M. D.
(Address) Asst Dir MGH
Date
4/2820 48
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
(Cemetery)
Winthrop
Winthrop
DATE OF BURIAL
May 1 1948
19
(City or Town)
22 NAME OF
FUNERAL DIRECTOR
E P Caggiano
ADDRESS
Winthrop
Received and filed
MAY 21 1948
.19
(Registrar of City or Town where deceased resided)
50m-(b).6-44-14607
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
No.
(City or Town) Mas.s. General Hospital
St.
Registered No.
which death
Of autopsy
Ag above
Due to.
Phila
18 DATE OF
DEATH
Widow
That
attended deceased
:
IR-302
1
PLACE OF DEATH
Suffolk
(County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF
Chelsea
(City or town making return)
Registered No.
30
No. Chelsea .... Memorial .... Hospital
..........
2 FULL NAME
Catherine Ann Ronayne
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residenoo.
No.
42 Wordsworth Ave ..
.....
st. .. Winthrop.
(Usual place of abode)
(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
4 COLOR OR RACE|
White
1
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Single
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
April 24, 19 48 to.
That i attended deceased from
April 28
19 ... 48 ..
I last saw h
er allve on.
April 28
19.48
death is said to
(or) WIFE of
(Husband's name in full)
have coourred on the date stated above, at
8:15 A
m.
Duration
Immediate cause of death
Prematurity
4 days
7 IF STILLBORN, enter that fact here.
8 AGE Years Months. 4 .... Days
if less than 1 day
.. Hours.
......
.Minutes
Usual
9 Occupation :
industry 10 or Business :
11 Social Security No ..
12 BIRTHPLACE (City)
(State or country)
Mass
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass
15 MAIDEN NAME
OF MOTHER
Ann Harrington
16 BIRTHPLACE OF
MOTHER (City)
East Boston
(State or country)
Mass.
Relation if any
17
informant
(Address )42 Wordsworth Ave. Winthrop
A TRUE COPY.
ATTEST:
(Registrar of city of town where death occurred)
DATE FILED 19
Of autopsy
As above
What test confirmed diagnosis ?.
Autopsy
20 Was disease or Injury in any way related to ccoupation of deceased ?
if so, speolfy.
(Signed).
Dante L .Adelizzi
M. D.
(Address) East Boston
Date
5/119 48
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Winthrop
Winthrop
DATE OF BURIAL
May 4
(Cemetery)
(City or Town)
19.48
22 NAME OF
FUNERAL DIRECTOR
Kirby ...... Bro.s.
ADDRESS
Winthrop
Received and filed
19
(Registrar of City or Town where deceased resided)
50m-(b) -6-44-14607
resided in another 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.)
PARENTS
Chelsea
Other conditions
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of.
4/30/48
Physician Underline the cause to which death should be charged sta- tistically. 1
Due to.
Atelectasis
Aspiration of Mucous
Due
Subarachnoid ... Hemorrhage
6 Age of husband or wife if alive
years
18 DATE OF
DEATH
April 28, 1948
Female
(If death occurred in a hospital or institution,
St.
give its NAME instead of street and number)
Chelsea (City or Town)
CERTIFICATE OF DEATH
(if U. S.
War Veteran,
spoolfy WAR)
r
5a if married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
MAY2219:3 TW
IR-301 A
DEATH in plain 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, G. L. Chap, 46 , Section 10, requires physicians to insert a recital to that effect.
-
Suffolk (County)
Winthrop
(City or Town) 115 Locust St
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. 31. Registered No ..
St. § (If death occurred in a hospital or institution, { give its NAME instead of street and number) }
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(WaPHYSICIAN-IMPORTANT
U. S. War Veteran,
if so specify WAR).
(a) Residence. No.
(Usual place of abode)
115
Locust St
St.
Length of stay : In hospital or institution
(Before death)
(Specify whether)
years
months
days.
(If nonresident, give city or town and State)
In this community35
yrs.
mnos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED Married
5a If married, widowed of divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
60
6 Age of husband or wife if alive.
years
7 IF STILLBORN, center that fact here.
8
AGE.61 .. Years.
Months
Days
If Icss than 1 day
Hours
Minutes
Usual
Painter
9 Occupation:
Industry
10 or Business:
11 Social Security No.
025 -- 12 -- 1988
12 BIRTHPLACE (City)
Boothbay
Me.
(State or Country)
13 NAME OF
FATHER
Wesley Pinkham
PARENTS
14 BIRTHPLACE OF
Boothbay
FATHER (City)
(State or Country)
Me.
15 MAIDEN NAME
OF MOTHER
Francena Hodgton
16 BIRTHPLACE OF
MOTHER (City)
(Statc or Country)
Me.
17 Informant.
Mary Pinkham
(Rofajidneif any)
(Address) 115 Locust St
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed withme BEFORE the burjabor transit permit was issued : Watter A Bakery
(Signature of Agent of Board of Health or other)
5/3/48
l (Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
MAY
(Mouth)
(Day)
(Year)
19
May
I HEREBY CERTIFY,
That I attended deceased from
19
45.
to.
5/1
yf., 19.
I last sawh I'm alive on
May
.. , 19.
. , death is said to
have occurred on the date stated above, at 5050 .. m. Immediate cause of death
Cerebral hemorrafi
Due to
Hypertension
Due to
generalized arterio
medical examiner waived jurisdiction
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations
Date of
Of autopsy.
Clinical
IMPORTANT Underline the cause to which death should be charged sta- tistically.
20 Was disease or injury in any way related to occupation of deceased? Wo
If so, specify.
Jane pleinsatt
(Signed)
(Address) 238 Shore Davies CalifDate of
1/2
.M. D.
1945
21
t. Benedict
Boston
Place of Burial, Cremation or Removal.
DATE OF BURIAL.
May.
4 1948"
19
{ity or Town)
22 NAME OF
FUNERAL DIRECTOR
John F. O Maley
ADDRESS
Winthrop
Received and Filed.
MAY
5 1948
.19
(Registrar)
100M-10-47-22153
1
PLACE OF DEATH
No
Justin C B.Pinkham
Health
Boothbay
What test confirmed diagnosis?
Duration
IMPORTANT 2 hours unknown
House.
Sullivan
1948
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.
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