Town of Winthrop : Record of Deaths 1944, Part 1

Author: Winthrop (Mass.)
Publication date: 1944
Publisher:
Number of Pages: 526


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1944 > Part 1


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org.


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87



I


J. L. FAIRBANKS DIV. Thomas Groom & Co. Stationers 105 State St., Boston


To duplicate this book order


No. 468-10


O.U.7


-


1


2


1


M R-301 A


PLACE OF DEATH


Suffolk (County) Winthrop


Oh 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


St.


§ (If death occurred in a hospital or institution, ¿ give its NAME instead of street and number)


2 FULL NAME


Rebecca Ellen (Cole) Chambers


(If deceased is a married, widowed or divorced woman, give also maiden name.)


2 Maple Road


St


(If nonresident, give city or town and state)


years


months


days.


In this community 5Oyrs.


mos.


days.


PERSONAL AND STATISTICAL PARTICULARS


5 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED


Widow


(Month)


(Day)


(Year)


19 I HEREBY CERTIFY, That I attended deceased from


June 13 19 43 to January 1 19. 44


I last saw her alive on December 3/ 1943, death is said to


have occurred on the date stated above, at 7 A m.


Immediate cause of death ... Cerebral Remontage


Duration IMPORTANT 24 hours


Due


denility


5 years ...........


Due to.


arteriosclerosis


Other conditions none (Include pregnancy within 3 months of death)


IMPSETANT


PHYSICIAN


Major findings:


Of operations


none


Date of.


Of autopsy.


none


What test confirmed diagnosis? clinical × laberating.


20


Was disease or injury in any way related to occupation of deceased ?.


200


If so, specify ...


(Signed Jacob


(Address) 562 Hurley


Winthrop chultags Winthrop


Place of Burial, Cremation or Removal. (City or Town)


DATE OF BURIAL.


Januaryr


4


Ig.


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:


22 NAME OF


FUNERAL DIRECTOR award J. Reynolds


ADDRESS 1800 Multirak


Received and filed


19


(Official Designation) (Date of Issue of Permit)


MEDICAL CERTIFICATE OF DEATH


18 DATE OF


DEATH ..


January


1


1944


(Give maiden name of wife in full)


Alexander Chambers


(Husband's name in full)


.years


If less than 1 day Hours Minutes


16 BIRTHPLACE OF


MOTHER (City) ..


(State or country}


New Brumswick


Relation, if any


Daughter21 ..


(Address)


2 Maple Rd. Winthrop


100m-2-'40-D-729-a


I


(City or Town)


No ..


2 Maple Road


(a) Residence. No.


(Usual place of abode)


Length of stay: In hospital or institution ..


(Specify whether)


3 SEX


Female


4 COLOR OR RÄCE


White


Sa If married, widowed, or divorced


HUSBAND of.


(or) WIFE of


6 Age of husband or wife if alive.


7 IF STILLBORN, enter that fact here.


8


AGE


Years


88


0


Months


2.0. Days


Usual


House Wife


9 Occupation :


Industry


At Home


10 or Business :.


Il Social Security No.


None


12 BIRTHPLACE (City) ..


New Brunswick


(State or country)


13 NAME OF


FATHER


Edmund Cole


14 BIRTHPLACE OF


FATHER (City)


15 MAIDEN NAME


OF MOTHER


Catherine Buck


PARENTS


IZ


Informant.


Alvina M Broderick


is very important. See instructions and extracts from the laws on back of certificate.


CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION


information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state


4


N. D .- WRITE PLAINLY, WITTY UNFADING DLACK INA-THIS IS A PERMANENT RECORD. Every item of


(State or country)


New Brunswick


(Signature of Agent of Board of Health or other) Health Etiche 1/4 /44


(Registrar)


6 years


Underline the cause to which death should be charged sta- tistically.


Date 1/13/44


M. D.


(If U. S.


War Veteran,


specify WAR)


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 lie 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 required by section one, where saine was contracted, the duration of his last illness, when last seen alive by tbe physician or officer and the date of his death . . . Gen. Laws, Chap. 46, Sec. 9.


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 receiv- ing 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 in- sufficient, a physician who is a member of the board of health, or em- ployed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall inake 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 re- moval 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 perinit. 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 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 require .- 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 received 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 bave 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


Tbe 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 discase 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 physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably 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 deatb 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 carlier 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 important, 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, however, 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


COPY OF CERTIFICATE OF DEATH


STANDARD CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE


Town or City


Clerk's No ...


A66 .


2


2. USUAL RESIDENCE OF DECEASED:


(a) State.


Mass.


(b) County


(c) City or town.


Withap


(d) Streot No.


(If rural give location)


(e) If foreign born, how long In U.S.A .? ___ years.


MEDICAL CERTIFICATE


20. DATE OF DEATH: Month


January


6


yoar


1944


hour


1


_minute


15A.M.


21. f HEREBY CERTIFY that f attended tho deceasod from


July


20


43


19


to


January5


19


44.


that I last saw h


allve on


13


and that doath cccurrod on the date and hour stated above


DURATION


Immediate cause of death Bronchi Aneumonia


4 days


Due to Carcinoma of skin


of face


3 years


Due to


Other conditions (Include pregnancy within 3 months of death)


Major findings: Of operations


Of autopsy


22. If doath was duo to oxternal causos, fill In tho following:


(a) Accidont, suicide, or homicide (spocify).


(b) Date of occurrence


(c) Where did Injury occur?


(City or Town)


(County)


(State)


(d) Did Injury occur In or about home, on farm, In Industrial placo, In public placo?


(Specify type of place)


While at work?


23. SIGNATURE


Francia D. C. Kuche


M.D. or other


2.0.11


Dato signod


1-6-44


Addross


Center assifue, n.N.


Clerk of


asaju


Dated


2/5


44 4


19 ....... Y


WITH UNFADING INK. Every item of information should be carefully supplied. ly important. Physicians: please write the causes of death clearly and legibly.


DEPARTMENT OF COMMERCE


Bureau of, the Census


FULL NAME_


Jus Bertha Wilson


1. PLACE OF DEATH:


(a) County


Carole


(b) City or town


Carroll County Home


(c) Namo of hospital or Institution:


(If not in hospital or institution write street number or location)


(d) Length of stay:


fn hospital or Institution


5 1/2 months


(Specify whether years, months or days)


In this community


(Specify whether years, months or days)


3(a) xx XXXX


3(b) If veteran, name war


3(c) Social Security No.


4. Sex


5. Color or race


Female White


6.(a) Single, widowed, marriod, divorcod


widowed


6.(b) Name of husband or wifo:


(Foll como -- Maiden name if wife)


6.(c) Age of husband or wife If all ve ...


7. Birth date of decoased


Sept.


(Month)


28 1868


(Day)


(Year)


8. AGE: Years


75


Months


3


Days


8


hrs. min.


9. Birthplace


Reading


(City, Town, or County)


(State or Forelgn Country)


10. Usual occupation.


Housewife


11. Industry or business.


FATHER


13. Birthplaco


(City, Town, or County)


(State or Foreign Country)


14. Maiden name 7


15. Birthplace


(State or Forelgn Country)


(City, Town, or County)


Charles Severance


16.(a) Informant's own signature


(b) Address


Ossipee, n.H.


17.(a) Buscal


(b) Dato thereof


San. 8,'44


(Month)


(Day) (Year)


(Burial, Cremation, or Removal) Lindenword, Reading


(c) Placo: Burial or cromation


18.(a) Signature of funeral director


bleu a. Lord


(b) Address


West arsifue, D.N.


Countersignod


(Agent City Board of Health)


19.(a)


(Date Recelved by City Board of Health)


(b)


Jan. 8, 1944.


Date Received by Town or City Clerk)


Signature of Town or City Clerk


Solu K. Hill


Clerk of Classes, n. W.


A true copy, Attest: John K. Will


PHYSICIAN


Undorlino the cause to which doath should be charged statistically.


MOTHER


__ yoars.


If less than ono day


12. Name. 7


1


maks.


(0) Means of Injury


day


XX


INANYWid ٧


A VyNI NDVIU UNIOVINn HLIA 'AiNIVid LIM-' 'N


* 49 41194


جرم


M R-301 A


1


Suffolk. (County) Winthrop (City or Tamno .... 42 franklin St. No. John Foto poules


The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH Winthrop, Mana


To be filed for burial permit with Board of Health or its Agent.


3


2 FULL NAME


( If deceased Is a married, widowed or divorced woman, give also maiden name.)


(a) Residence/


No.


42 Franklin St., Winthrop, s& Mars


...


(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 days.


In this community


yrs.


mos.


days.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


male


4 COLOR OR RACE


white


5 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


married


Sa If married, wideweb of divorsed Sagoula


HUSBAND of


(Give maiden name of wife In full)


(or) WIFE of


( Husband's name in fuli)


6 Age of husband or wife if alive 44 years


IF STILLBORN. enter that fact here.


8


AGE 50 Years


Months


Oays


If less than 1 day


Hours.


.Minutes


Usual


9 Occupation :


Proprietà


10 or Business :


Industry


Shoe Repair


11 Social Security No.


12 BIRTHPLACE (City)


( State or country)


Grecco


13 NAME OF


FATHER


Elias Fotopoulos


14 BIRTHPLACE OF


FATHER (City)


Greece


(State or country)


15 MAIDEN NAME


OF MOTHER


Pagona Athanasopoulou


16 BIRTHPLACE OF


MOTHER (City)


(State or country)


Greece


17 Informant.


Relation, if any Pagona Futopoulos with (Address) 42 Franklinist, Winthite, Mass


i HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : William S. Children


(Signature of Agent of Board of Health or other) agent Can 8/44


(Official Designation) (Date of Issue of Permit)


18 DATE OF


DEATH


tan


( Month)


(Day)


1944


(Year)


19 | HEREBY CERTIFY,


That I attended deceased from


19.


Ło


19 ....


I last saw h ...


.. allve on


death is sald to


19


have occurred on the date stated above, at.


8: 10 a.


m.


Duration


Immediate oause of death.


Coronary Infant


IMPORTANT


Due to.


Other conditions.


( Include pregnancy within 3 months of death)


Major findings :


Of operations


Oate of


Of autopsy


What test confirmed diagnosis?


20 Was disease or injury in any way related to occupation of deceased ?


If so, specify


('Signed)


(Address)


www ......... Date ...


-. 19.


21


Winthrop Cem. Winthrop Man.


Place of Burial, Cremation or Removal.


9,


(City or Town)


DATE OF BURIAL ..


22 NAME DF


FUNERAL DIRECTOR


6 Putay C. Hacertis


ADDRESS


1654 Wasking for 57 Booby Man


Reoelved and filled .19


18 : (Registrar)


100M-6 -2-42-8855


If deceased was a U. S. War Veteran, G. L. Chap. 46. Section 10, requires physiolans to insert a recital to that offoot. extracts from the laws on back of certificate. terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and should be carefully supplied. ACE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain


PARENTS


....


IMPORTANT Physician


Underiino the cause to which death should be charged sta- tistically.


M. D.


...


Registered No. death occurred in a hospital or in ) give its NAME instead of street aud nuniber) r PLACE OF DEATH


PHYSICIAN · IMPORTANT


(Was deceased a


U. S. War Veteran,


if so spoolfy WAR)


EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE


RETURN OF CERTIFICATES OF DEATH


A physician or registered hospital medical officer shail forthwith, after the death of a person whoin he has attended during his last illness, at the request of an undertaker or other authorized person or of ans meniber of the family of the deceased, furnish for registration a standard certifcate 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 wss 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 helief, served In the ariny, navy or marine corps of the I'nited States in any war in which it has been engaged. insert in the certificate a recital to that effect, speci- fying the war, and shsil also certify in such certificate both the primary and the secondary or immerliste cause of death ss nearly as he can state the saine. 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 bundred and fourteen, the word "war" shall include the China relief ex- pedition and the Philippine insurrection, which shall, for said purposea, he deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Stexi- can border service of nineteen hundred and sixtcen and nineteen hundred and seventeen. G. L. Chiap. 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 huinan body and remove it froin a town, from one cenietery to another, or from one grave or tomb other thau 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 inay 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. o1 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 hesith, or employed by it or by the aelectmen for the purpose, shall upon application niake 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, froin one town to another within the cominonwealth cannot be obtained early enough for the purpose, the certificate of desth made as above provided and in the possession of the undertaker desiring to make such removal shsil 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 removsl, 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 aerved in the army, navy or marine corps of the United States in any war in which it has been engaged. sucb 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 matter of cause of the death, which the clerk or registrar may require .- 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 luto 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 he held, or from a person ajointed to have tbe care of the cemetery or burial ground in which ibe interment is made .... Chap. 114. Sec. 46. G. L., (Tercentenary Editiou).


Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died hy violence. If a medical examiner bas notice that there is within his county the hody of such a person, he shall forthwith go to the place where the body liea and take charge of the same; ... - General Laws, Chap. 38, Sec. 6.


RULES OF PRACTICE


The fulfillment of the purpose of these laws calla for the observance of the following rules of practice :


(1) Attending physiciana will certify to such deatha only aa those of persons to whom they have given bedside care during a last illuess from disease unrelated to any form of injury.


(2) Board of Health physiolans will certify to such deaths only as those of persons who, though disahled by recognized disease unrelated to any form of injury. have died without recent medical atteinlance or whose phyaf- cian is absent from home when the certificate of death is needed.


(3) Medioal Examiners will investigate and certify to all dicatha sup- posably due to Injury. These include not only deaths caused directly or in- directly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following shortion, but also deaths from diacasa resulting from Injury or Infection related to oooupation, the audden desths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death. Cause of deathi meana 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 cauaîng 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 Oooupatlon .- Precise statement of occupation la very Im- portaut, 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 ou account of the disease causing desth, report the usual occupation prior to Illness. If the deceased hsd retired from businesa, report the usual occupation prior to retirement. Children not gainfully employed may be returned aa at school or at hoine. For a woman whose only occupation wsa that of home bousework, write bousework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terma, as bousekeeper-private family, cook-hotel, etc. For a person who bad no occupation whatever write none.


SPACE FOR ADDITIONAL INFORMATION


Jevany 0610


M R-301 A


1


Winthrop


The Commontoralth 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.


S ( If desth occurred in a hospital or Institution, I give its NAME instead of street aud nuniber)


PHYSICIAN - IMPORTANT


2 FULL NAME.


William J. Clark


(If deceased Is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No.


.21 ..... Grovers .... A.ve


(Usual place of abode)


St.


(If nonresident, give clty or town and State)


Length of stay: In hospital or Institution




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