USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1948 > Part 72
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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 deathis caused directly or indirectly by traumatism (including resulting septicemia), and hy 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 he 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
M R-302
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.)
1
Boston
(C'ity or Town) Mass. General Hospt No.
The Commonmoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
88653
( If death occurred in a hospital or institution, St. give its NAME instead of street and number)
2 FULL NAME
Gertrude M Hill
(If deceased is a married, widowed or divorced woman, give also maiden name.)
59 Summit Ave.
St.
Winthrop
Mass.
(a) Residence. No.
(Usual place of ahode)
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution.
(Before death)
(Specify whether)
years
months19
day 8.
In this community
yrs.
.19
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
F
4 COLOR OR RACE| 5 SINGLE
W
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
5a If married, widowed, or dlvoroed HUSBAND of
(or) WIFE of
(Give maid
Hij] [' wife in full)
(Husband's name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that faot here.
8 AGE87
Years
2
Months
13
Days
If less than 1 day
Hours.
.Minutos
Usual
9 Oooupation :
Housewife
Industry
10 or Business :
Own Home
11 Social Security No ....
None
12 BIRTHPLACE (City)
(State or country)
.... Maine
PARENTS
14 BIRTHPLACE OF
Unable to obtain
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Unable to obtain
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Unable to obtain
17
Informant
(Address)
E.M. Mitchell( RelaDanigifter
A TRUE COPY
ATTEST
(Registrar of city or town where death occurred)
DATE FILED
Oct/14/48
7
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Oct. 11/48
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
Sept .25
18
.,
19
to
That I attended deceased
Oct ...
.11
19
18"
I last saw h ....... er .... allve on
Oct. 11
19 48
, death Is sald to
have occurred on the date stated above, at.
9:30AM
.m.
Immediate cause of death
Cerebral thrombosis
Due to.
Due to.
Other conditions.
(Include pregnancy within 3 months of death)
Physician
Major findings :
None
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 ?.........
If so, specify
(Signed)
CL Clay
(Address)
Mass. General Hospt
Date.
10-17, 48
Glenwood Cem-Everett Mass.
21 "PLACE OF BURIAL,
CREMATION OR REMOVAL
CCpeter1/3/48
(City or Town)
DATE OF BURIAL
19
22 NAME OF
FUNERAL DIRECTOR
H S Reynolds
ADDRESS
Winthrop Mass.
Received and filed OCT 22 1948
19
(Registrar of City or Town where deceased resided)
1
Duration 5 Days
13 NAME OF
FATHER
Umable to obtain
25M-(f)-11-42 10746
PLACE OF DEATH
Suffolk
(County)
-
2
(If U. S.
War Veteran,
speolfy WAR)
from
George ... N wame
M R-305
Suffolk
(County)
Boston
(City or Town)
No.
475 Mass.Ave.
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
8958.1
(If death occurred in a hospital or institution,
give ita NAME instead of street and number)
2 FULL NAME
George Betts
(If deceased ie a married, widowed or divorced woman, give also maiden name.)
259 Bowdoin St
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 1 5 yrs.
moa.
days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE[
W
5 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
5a If married, widowed, or divorcedma Pommet
(Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife If allve
years
7 IF STILLBORN, enter that faot here.
8
AGE
Yeare.
Months.
Days
If less than 1 day
....
Hours ........
.. Minutes
Laundry Business
11 Social Security No ..
.Walpole ... Mass.
13 NAME OF
FATHER
George L Betts
14 BIRTHPLACE OF
Boston Mass.
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Mary Crowley
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17
Informant.
(Address)
Wife
Relation, if any
A TRUE-COPY Del XX
ATTEST:
....
(Registrar of city or town where death occurred)
DATE FILED
Oct. 18
19
48
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Oct. 14/48
(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, etate fully.) Coronary sclerosis
treated therefor with positive E.K.G
20 Acoldent, sulolde, or homlolde (specify)
Date of ooourrenoe.
19
Where did
Injury ocour ?
(City or town and State)
Did Injury ooour In or about the home, on farm, In Industrial place, or In
pubilo place?
(Specify type of place)
Manner of
Injury
Collapsed after climbing 3
Nature of
flights of stairs
Injury
While at work ?.
Was there an autopsy ?..
.N.Q
21 Was dleease or Injury In any way related to occupation of deceased ?.
If so, speolfy ..
(Signed)
Timothy Leary
...
M. D.
(Address)
Date 10-15 19
48
22
Winthrop Cem Winthrop Mass.
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
Oct. 18/18
19
23 NAME OF
FUNERAL DIRECTOR
K W Kirby
ADDRESS
Winthrop Mass.
Received and filled.
OCT 22 1948
19
(Registrar of City or Town where deceased resided)
25m-(d)-6-43-12056
3 SEX
HUSBAND of
(or) WIFE of
60
Usual
9 Oocupation :
PARENTS
occurred. (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-805 to the clerk
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
Industry
10 or Business :
of the city or town in which the deceased resided as soon as possible after the close of the month in which the death
PLACE OF DEATH r
1
St.
(If U. 8.
War Veteran,
speolfy WAR)
Winthrop Mass.
(a) Residence. No.
(Usual place of abode)
59
Laundry
12 BIRTHPLACE (City)
(State or country)
+
PLACE OF DEATH -
Suffolk
Breton 11/5/48
Winthrop
( City or Town)
No. Winthrop Community Hospital
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
Registered No.
205
St.
{ {If death occurred in a hospital or institution,
{ give its NAME instead of street and number)
2 FULL NAME
Helen ... M ..... Walters
( If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
6 Bellvista Road
(Usual plece of abode)
St.
Brighton
Mass
(If nonresident, give city or town and State)
Length of stay : In nosoltal or Institution
Hospital
(Before death)
( Specify whether)
years
months
6
days.
In this community
58yrs. 1 mor. 22 days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE!
White
5 SINGLE
MARRIED
WIDOWED
( write the word)
or DIVORCEDSingle
5a If married, widowed, or divoroed
HUSBANO of
(Give maiden name of wife in full)
(or) WIFE of
( Husband's name in full)
6 Age of husband or wife if alive
yaers
7 IF STILLBORN, enter that fact here.
AGE
8 58 Years 1 Months 22. Days -
If less then 1 day
Hours
Minutes
Usual
9 Occupetion :
Clerk
Industry
10 or Business :
Newspaper ..... Co.
11 Social Security No.
012-01-7637
12 BIRTHPLACE (City ) .. Bo.s.t.on,
( State or country)
Mass.
13 NAME OF FATHER James M. Walters
14 BIRTHPLACE OF
FATHER (Clly)
Charlestown
(State or country)
Mass.
15 MAIDEN NAME
OF MOTHER
Catherine Mclaughlin
16 BIRTHPLACE OF MOTHER (City) (State or country)
Ireland
17 informan Catherine Walters (Address) 6 Bellvista Rd. Brighton, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of deeth wes fied with me BEFORE the burling of transit permit was Issued : Walter . Baklig. Signature of Agont of Board of Health of other)
10/15/18
(Date of Taque of Permit)
18 DATE OF
DEATH
October
15,
1948.
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
Thet I attended deosased from
Oct8
1948.
to
Oct15
19
480
i last saw her
allve on ...
Oct 15
.1944, death Is sald to
have occurred on tha date stated above, at.
1.30 A
m.
Immediate cause of death arteriosclerotec Least
disease
Dus to
arterionem
Due to
Other conditiona.
( Include pregnancy within 8 months of death)
Major findIngs :
Df operations
Date of
Of eutopsy
What test confirmed dlegnosis?
Electrocando
IMPORTANT
Physician Underline the cause to which death should he charged sta. Theically.
20 Was disease or injury in eny way related to oooupation of deceesed ? if so, spaoify
( Signed )
(Address)
Date 10-11 1948
21 New Calvary Boston, Mass
· DATE OF BURIAL.
Place of Burial, Cremation or Removal.
October
18,
(City or Town)
48.
19.
22 NAME OF
FUNERAL DIRECTOR
Edward
Safer Sons
ADORESS
Medford, Massachusetts.
Reoalved and Ålad OCT 2 0 1948 .19
( Registrar)
JAtracts 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 reoitai to that effeot. PARENTS
R-301 A
100m(i).1.44-13634
Health (Official Designation)
MEDICAL CERTIFICATE OF DEATH
Duration
IMPORTANT 1946
July
M. D.
1
PHYSICIAN. - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
None
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 relief 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 nianner 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
M R-302
PLACE OF DEATH
Suffolk (County)
The Commontoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Boston
(City or town making return)
1
Boston
(C'ity or Town)
Yeter Bent Prigham Hospital
No.
un
(If death occurred in a hospital or institution,
St.
give its NAME instead of street and number)
Morris Ross
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
211 Shirley
winthrop Mass.
St.
(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 8
yTs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
years
7 IF STILLBORN, enter that fact here.
8
AGE
70
Years.
Months.
.Days
If less than 1 day
Hours
Minutes
Usual
9 Oooupation :
Grocer Self
Industry
10 or Business :
Retail Goods
11 Social Security No.
None
12 BIRTHPLACE (City)
(State or country)
Russia
PARENTS
14 BIRTHPLACE OF
Russia
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Leah
--
16 BIRTHPLACE OF
Russia
MOTHER (City)
(State or country)
17 I E Ross
Relatiqhij if eny
Informant.
(Address)
A TRUE COM
ATTEST.
(Registrar of citf or town where death .occurred) . ..
DATE FILED
Oct. 19
1948
18 DATE OF
DEATH
(Month)
Oct. 16/48
(Day)
(Year)
19 [ HEREBY CERTIFY,
Oct. 12
19.
to
That I attended deceased
Oct.
16
19
from
I last saw h ... im
.... alive on
Oct. 16
19
death is sald to
have ocourred on the date stated above, at.
12;01A
m.
Immediate cause of death.
Bleeding duodenal ulcer
Duration 10 Yr's
Term.
Due to
Pneumonia
Due to.
Pericarditis
Term.
Other conditions.
(Include pregnancy within 3 months of death)
Physician
Major findings :
Of operations
None
Underline the cause to which death should be
Of autopsy
None
What test confirmed diagnosis?
20 Was disease or injury in any way related to oocupation of deceased ?
If so, specify
G W Thorn
(Signed)
(Address)
P. Bent Brigham Hosph. 10-15- 18
21 "PLACE OF BURIAL, Koyner Umgegend West Rox.
CREMATION OR REMOVAL
(Cemetery)
Oct ...
17/48
(City or Town)
DATE OF BURIAL
19
22 NAME OF
FUNERAL DIRECTOR
H J Torf
ADDRESS
Chelsea ... Mass ..
Received and filed 19
(Registrar of City or Town where deceased resided)
25M-(f)-11-42 10746
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.)
13 NAME OF
FATHER
Ross
Date of
Clinical
charged sta- tistically.
6 Age of husband or wife if alive
54
Ida Krasnecovitz
(If U. S.
War Veteran,
speolfy WAR)
Registered No.
898206
R-303-A
PLACE OF DEATH
Suffolk (County) Winthrop. (City or Town) ... 25 Prospect St. are william ole (correct name)
The Commontoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burlal permit with Board of Health or Its Agent.
Registered No.
2022
St. { {If death occurred in a hospital or institution, ¿ give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman give ,also maiden name.)
(a) Residenoe. No. 25 Prospect St. Nunthroat.
(Usual place of abode)
art,
Length of stay : In hospital or institution.
(Before death)
( Specify whether)
years
months
days.
In this community
5 утв.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
5a If marrled, widowed, or diyorged Cohen
HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if allve 32
years
If less than 1 day Hours. ......... .. Minutes
12 BIRTHPLACE (City)
(State or country)
New York, N. Y.
13 NAME OF
FATHER
Rubin Cohen
FATHER (City)
Rumania
(State or country)
Roumania
15 MAIDEN NAME
OF MOTHER
Bessie Abramovitz
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Roumania
Rumania
( Address) 25 Prospect Ave. , Winthrop
I HEREBY CERTIFY that a satisfactory standard, certificate of death was filed with me BEFORE the burial or transit permit was issued : Walter & Maker
(Signature of Agent of Board of Health or other)
Health Appecet 10/19/48
(Official Designation) (Date of Issue of Permit) /
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
October -18-1948 ( Month) (Year)
(Day)
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 involfed, state fully.) acute Cardiac facture:
Rheumater Heart Disease Carenames Sclerosis
20 Aocident, suloide, or homiolde (specify)
Date of goourrenoe
19
Where did
Injury opour ?
(City or town and State)
Did Infury ooour In or about home, on farm, in Industrial place, or in publio
piaoe ?
(Specify type of place)
Injury
Mann
refound dead in his bed
Nature of Injury
While at work ?.
.Was there an autopsy ?.
200
21 Was disease or Injury In any way related to oooupation of deceased?
if so, specify
Min. Suckles
(Signed)
M. D.
(Address)
Peut. 18-1948
22 Mt.Lebannon-Mohliver-West Roxbury
Place of Burial, Cremation or Removal.
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