Page images
PDF
EPUB
[merged small][ocr errors][merged small]

229

Department of Health of the City of New York,

Bureau of Records

Certificate of Death 27233—Registered No.

AAA908 1932

230

1. Place of death, Borough of Manhattan. No., Manhattan-General Hospital. Character of premises, Hospital.

2. Full name, William DeVellier.
3. Sex, Male.
4. Color or race, White.
5. Single.
6. Date of birth.
7. Age, 24.
8. Occupation, Theatre manager.
9. Birthplace, United States.
9a. How long in U. S., Life. N. Y. C., Life.
10. Name of father, Wm. DeVellier.
11. Birthplace of father, France.
12. Maiden name of mother, Charlotte White.
13. Birthplace of mother, England.
14. Special information, etc..
Usual residence, 96-08 42nd Ave., Corona, L. I.
15. Date of death, Dec. 20th, 1932.

16. I hereby certify that the foregoing particulars (Nos. 1 to 15 inclusive) are correct as near as the same can be ascertained, and I further certify that I have this 21st day of December, 1932, taken charge of the body of deceased found at City Mortu

231

Death certificate, Dec. 22, 1932

232

ary and that I have investigated the essential facts concerning the circumstances of the death.

17. I further certify that I have viewed said body and from autopsy and evidence, that he died on the 20th day of December, 1932, at 12:10 P. M. and that the chief and determining cause of his death was embolus to right ventricle and pulmonary artery ten days after right inguinal herniotomy.

Milton Helpern,

Assistant Medical Examiner.

Charles Norris, M.D., Chief Medical Examiner.

233

Filed Dec. 22nd, 1932.

18. Place of burial, Flushing Cem. Date of burial, Dec. 23rd, 1932.

19. Undertaker, Joseph Urban, Inc. Address, Winfield, L. I.

John H. Possimiede, 2382.

This is to certify that the foregoing is a true copy (photographic) of a record on file in the Bureau of Records, Department of Health, City of New York.

[merged small][merged small][ocr errors]

Proof of death, Dr. Bohrer, Jan. 13, 1933

PROOF OF DEATH, DR. BOHRER,

JAN. 13, 1933 Form C-64

235

State of New York

Department of Labor

Office of the Industrial Commissioner

Bureau of Workmen's Compensation

Syracuse Office: 214 South Warren Street

Case No......

Ins. Carrier's No........

236

1. Name of the deceased in full, William DeVellier; address, 96-08 42nd Ave., Corona.

2. Age at death, 24 years. Married or single? Single.

3. Name of employer, Century Circuit, Inc.; address, 152 W. 42nd St.

4. How long have you been medical adviser of deceased ? Dec. 8th, 1932. 5. Date of accident, Sept. 5th, 1932.

Sept. 5th, 1932. Date of death, Dec. 20th, 1932.

6. Date of your first visit, Dec. 8th, 1932. Date of last visit, Dec. 20th, 1932.

7. Place of death, Manhattan General Hospital, Lex. & 90th St., N. Y. City.

8. Who engaged your services ? Aetna Life Insurance Co.

9. State in patient's own words how the accident occurred, He picked up a woman who had fainted and carried her up a flight of stairs.

237

Proof of death, Dr. Bohrer, Jan. 13, 1933

238

10. Give a complete and accurate description of nature and extent of injury, as you found it upon first and subsequent examinations, Indirect inguinal hernia.

11. State the direct cause of death, Pulmonary embolus.

12. In your opinion was the accident as above described a cause either directly or indirectly of the death ? A. Ind.

13. Give contributory causes, if any, Operation followed by pulmonary embolus.

14. If coroner's inquest held, give coroner's name and address, Medical examination for City of New York.

15. Was deceased attended by any other physician during last illness? If so, name and address, None.

16. I am a physician duly licensed in the State of New York, and graduated in the year 1914 from Cornell Medical College.

239

J. V. Bohrer, Attending Physician.
Address, 116 E. 58th St.

Dated, Jan. 13, 1933.

240

State of New York, County of New York, ss.

J. V. Bohrer being duly sworn, deposes and says: That he is the physician who subscribed to the above (or attached) report; that he has read the same and knows the contents thereof; that the same is true to the knowledge of deponent, except as to the matters Proof of death, March 3, 1933

therein stated to be alleged on information and belief, and as to those matters he believes it to be

[ocr errors]
[blocks in formation]

243

1. Name of the deceased in full, Devellier, Wm. Address...

2. Age at death, 22 or 23 years. Married or single? Single.

3. Name of employer, Schwartz Bros. Cent. Circ. Address......

4. How long have you been medical adviser of deceased ? Dec. 9th to Dec. 20th, 1932.

5. Date of accident, Dec. 5th, 1932. Date of death, Dec. 20, 1932.

« PreviousContinue »