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V I PLACE OF DEATH S iOF Wi YORKK


Department of Health of The City of New York
RUREAIU OF RF COR


Name of I..titutio ..... .. ..... .. .. .........
-'FULL NAME..L.ea Stoopiker __
3 SEX J4 COLORor RACE 5 SINGLE.
MARRIED,
WUD.
_______ \Tite OR DIVORCED
Female "Thite (Writ the word)
6 DATE OF BIRTH


................. ......... .. ... ..............
(Month) (Dar) ('ear)
7 AGE LESS t
4 1 day..-..J....a
1 .......yrs ................o.. ................ i or .......-....... n.
S OCCUPATION
(a) Trade, profesion or
partic ar kind of work............. ...................................................
(b) Goenea nature of i dustfl,
business or establishment in
which employed (or employer)............................................
9 BIRTHPLACE


(State or country)
Rui
(f How longing rri
.)'. S ,ie of fof-0
eign birth) 10/
S10 NAME OF
i FATHER
or---3an
o 11 BIRTHPLACE
SOF FATHER
Q (State or county
o 12 MAIDEN NAM
OF MOTHER
I-
M 13 BIRTHPLACE
4 OF MOTHER
fl. (State or count
14 Spre INFORMATION
Inslttions and in deaths


< -
........
*Ysu c]f~< --


A
4 OUGH OF .......


16 I hereby certify that the foregoing partic-
ulars (Nos. 1 to 15 inclusive) are correct as near
as the same can be ascertained, and I further certify
that deceased was admitted to this institution on
f3iLBr .41 4t-h ----- I9-... thait iast
saw h-..A -alive on the-..--.da of-
19..2 that...he died oA the_-. --..__dav of
_Cto ..-_--r 19_.. about 44...o'clock
V. or P. M., and that I ami unable to state definitely
the cause of death; the diagnosis during hi... .......
l.illness was:
o*risfcaC^


: Contributor a....

ved (9 How longresident
% B1 inityofNew AZ .d
4/2 or...ration
\Vitness my hapl this .dayo .......
k.A, t ;.hi- -- .a .
Signatuca.r.-. C-^. '^.i-a-p- -' -
h tap use- Q..ni Uica1.al...ft..f -....i.....
^ah ( Ellis Island. N.Y.
Y) s_ 17 c' hereby certify that I have this ....... dav of
E ....... .... .........19..-.... performed an autopsy
Chaa Rosenbuaum upon the body of said deccasd, and that the cause of
h ......... .death was as follows:
ry) Rus i
Required in de athi in ihospstals and
uf nun-residents arnd rec ret idents. ... .......... ............ ...... ... ...-- ..........-


d. if not at place o. death? Signature...... ......-....- ........... ).

Pathologist...........-. ...... Hospital

...... ... LACE OF BURIAL 1 DATE BURIAL
_.- ADD..RE SS 19a
A DDRESS- %.nss ) i


H'-' ---Sir-T


STANDARD CERTIFICATE OF DEATH NI
s... sla nd. .. Regs N............. ..... .


15 DATE OF DEATH
October 27 ,~2
...- ............----.............. .' (D.' (Year)
(Month) (Day) (Year)


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NEW YORK CITY DEPARTMENT OF RECORDS AND INFORMATION SERVICES
MUNICIPAL ARCHIVES
31 Chambers Street
New York, N.Y. 10007

This exact copy of a certificate should not be accepted unless the
raised seal of The Department of Records and Information Services is affixed thereon.
The reproduction or alteration of this transcript is prohibited by Section 3.21 of the
New York City Health Code.

In issuing this copy of the record, the Department of Records and Information Services
does not certify to the truth of the statements made thereon, as no inquiry to the facts
has been provided by law.


Leonora A. Gidlund
Director, Municipal Archives


Cran G.Anderss n
Commissioner, Dartment of Records







TO PHYSICIANS
1. The attending physician must furnish a certificate to the Department of Health within 36
hours after dea:h. and where death has rc\slted from infectious or contagious disease a certificate
must be furnished by him forthwith I Saniary Code, Sections 33 and 90).
2. All physicians practicing in The City of New York (including those in public institutions)
must be registered in the Bureau of Records (Sanitary Code, Section 218).
3. If a person dies from criminal violence or by a casualty or by suicide, or suddenly
while in apparent health, or when unattended by a physician or in prison, or in any suspicious
or unusual manner, it shall be the duty of any citizen who may become aware of the death of any
'uch person to report such death forthwith to the office of the chief medical examiner, and to a
police officer who shall forthwith notiiy the officer in charge of the station house in the pol;ee
i recinct in which such person died. Any person who shall wilfully neglect or refuse to report such
death or who without written order 'rom a medical examiner shall wilfully touch, remove or dis-
turb the body of any such person, or wilfully touch, remove, or disturb the clothing, or any article
upon or near such body, shall be guilty of a misdemeanor. (Inserted by Laws 1915, Chapter 284,
Section 2. In effect January 1, 1918.)
4. Certificates will be returned for additional information which give any of the following
dik:ises, without explanation, as the sole cause of death:
Abortion, Hemorrhage. Meningitis, Phlebits,
Cellulitis, Gangrene, Metritis, Pyaemia,
Childbirth, Gastritis, Miscarriage, Septicaemia,
Convulsions, Erysipelas, Peritonitis, Tetanus.
(Any one of these may be the result of an injury, and thus be a subject for investigation by
a Medical Examiner. If it is not, the certificate should make that fact plain.)
5. No certificate giving "Heart failure," "Dropsy," or other mere symptom as the sole
cause of death will be accepted, unless accompanied by a satisfactory written explanation.
6. Statement of Occupation.-Precise statement of occupation is very important, so that the
relative healthfulness of various pursuits can be known. The question applies to each and every
person, irrespective of age. For many occupations a single word or term on the first line will be
sufficient, e. g., Farmer or Planter. Physician. Compositor, Architect. Locomotive Engineer, Civil
Engineer, Stationary Fireman, etc. But in many cases, especially in industrial employment, it is
necessary to know (a) the kind of work and also (b) the nature of the business or industry, and
therefore an additional line is provided for the latter statement: it should be used only when needed.
As examples: (a) Spinner, (b) Cotton Mill, (a) Salesman, b) Grocery, (a) Foreman, (b) Auto-
mobile Factory.
TO UNDERTAKERS
1. No burial permit can be obtained without a proper certificate.
2. Certificates must he written throughout in black ink.
3. No certificate will be accepted which is mutilated, illegible, inaccurate, or any portion.
of which has been erased, interlined, corrected or altered, as all such changes impair its "alue
as a public record. j- ,
I hereby certiiy-lbat I have been employed as undertaker by.. _..7

the ....... .............of deceased. This sttement is made to obtain a permit

for the hurial or cremation of the remains of deceased.. ........

Sina......





















NEW YORK CITY DEPARTMENT OF RECORDS AND INFORMATION SERVICES
MUNICIPAL ARCHIVES
31 Chambers Street
New York, N.Y. 10007

This exact copy of a certificate should not be accepted unless the
raised seal of The Department of Records and Information Services is affixed thereon.
The reproduction or alteration of this transcript is prohibited by Section 3.21 of the
New York City Health Code.

In issuing this copy of the record, the Department of Records and Information Services
does not certify to the truth of the statements made thereon, as no inquiry to the facts
has been provided by law.


Leonra A. Gidlund
Director, Municipal Archives


rian G. Anderss
Commissioner, artment of Records