USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1853-1885 > Part 2
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Schaue Floyd
Undertaker
Dated at ___
on ..
14130
1868
* If a Married Woman or a Widow. +(W.) White. (A ) African (M ) Mixed White and African If of other Rares, specify what.
[Be very particular to fill all Blanks.]
August 14. 180; Winthrop
_____ Years,
4 Months,
Days.
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred, (or the deceased resided,) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof-or report these facts-to said Clerk. Penalty for neglect, twenty dollars.
Blank forms of Returns may be obtained from the Town Clerk.
To the Clerk of the Town in which the Death occurred.
1. Name,
.
Quelleze
live Pale
(Maiden Name,)*
2. Date of Death, .
Nefit 17 . 1864
3. Place of Death,
.
A Viriltarafa
4. Residence,
5. Sex, and whether Single, Married, or Widowed,
Female Single
6. Age,
51 Years, _.
10 Months,
Days.
1V
7. Color,t
·
8. Occupation,
9. Disease or
First or Primary, .
Cancer
Cause of
Secondary, (if any,)
Death,
·
By whom certified,
10. Place of Birth,
Chelsea
.
11. Place of Interment, ,
·
12. Name of Father, ·
13. Birthplace of Father, o
14. Name of Mother,
·
.
Hannah. stale, 1
15. Birthplace of Mother,
Signature of Undertaker or other person making the Return,
Dated at.
on fare 30
186 8
* If a Married Woman or a Widow.
t(W ) White (A ) African (M ) Mixed White and African. If of other Races, specify what.
[Be very particular to fill all Blanks.[
Wintherefo
fatura "falé Inhelsea
Undertaker
The Undertaker, or other informant, is requested to report the facts-together with the Physician's 'Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death oeeurred, (or the deceased resided,) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof-or report these facts-to said Clerk. Penalty for neglect, twenty dollars.
Blank forms of Returns may be obtained from the Town Clerk.
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
/
.
-
1
1
////// /11.1
(Maiden Name,)*
2. Date of Death, .
3. Place of Death,
11. 11 ttici
4. Residence,
5. Sex, and whether Single, Married, or Widowed,
6. Age,
88 Years, i
Months,
Days.
7. Color,t
8. Occupation,
9. Disease or First or Primary, ,
Cause of Secondary, (if any,)
(
10
Death, . By whom certified,
10. Place of Birth, .
11. Place of Interment, . .
12. Name of Father, .
13. Birthplace of Father, €
14. Name of Mother, ·
.
15. Birthplace of Mother,
Signature of Undertaker or other person making the Return,
1
11 jul 11.
1
Dated at.
18
* If a Married Woman or a Widow.
+(W ) White (A ) African (MI ) Mixed White and African. If of other Races, specify what.
[Be very particular tc fill all Blanks .;
1. Name,
.
J
11
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred, (or the deceased resided,) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof-or report these facts-to said Clerk. Penalty for neglect, twenty dollars.
Blank forms of Returns may be obtained from the Town Clerk.
3.00.
RETURN OF A DEATH. To the Clerk of the Town in which the Death occurred.
1. Name,
(Maiden Name,)*
2. Date of Death, .
11
3. Place of Death,
4. Residence, ·
·
5. Sex, and whether Single, Married, or Widowed,
6. Age,
Years, .__.
L __ Months,
Days.
7. Color,t .
8. Occupation, .
9. Disease or
First or Primary, .
Cause of Secondary, (if any,)
1<
Death,
)
By whom certified,
10. Place of Birth, .
.
1
11. Place of Interment, .
12. Name of Father, ·
£_2
13. Birthplace of Father, .
14. Name of Mother, ·
15. Birthplace of Mother,
Signature of Undertaker or other person making the Return,
Dated at.
on
1
18 --
* If a Married Woman or a Widow.
+(\.) White. (A ) African. (M ) Mixed White and African If of other Races, specify what.
[Be very particular to ûll all Blanks.]
.
1
-
·
1
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred, (or the deceased resided,) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof-or report these facts-to said Clerk. Penalty for neglect, twenty dollars.
Blank forms of Returns may be obtained from the Town Clerk.
RETURN OF A DEATH. To the Clerk of the Town in which the Death occurred.
1. Name,
.
(Maiden Name,)*
2. Date of Death, .
1 ×
3. Place of Death,
4. Residence,
11
5. Sex, and whether Single, Married, or Widowed,
6. Age,
7. Color,t
·
8. Occupation, ·
9. Disease or First or Primary, .
Cause of Secondary, (if any,)
Death, · L By whom certified,
10. Place of Birthi, ·
·
11. Place of Interment, .
12. Name of Father.
.
13. Birthplace of Father, ·
1
1
14. Name of Mother,
.
15. Birthplace of Mother,
/
Signature of Undertaker or other person making the Return,
Dated at
18
.
.. Ycars,
4 Months,
Days.
1
,
9/11/11.
1
.
1
* If a Married Woman or a Widow. t(W.) White (A ) African (M ) Mixed White and African. If of other Races, specify what.
[Be very particular to fill all Blanks. ]
11
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred, (or the deceased resided,) having first been obtained, the person having charge of such Interment inust FORTHWITH GIVE NOTICE thereof-or report these facts-to said Clerk. Penalty for neglect, twenty dollars.
Blank forms of Returns may be obtained from the Town Clerk.
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
1. Name,
.
Lucy Robinson -
(Maiden Name,)*
2. Date of Death, . ·
Sept 9 1869
3. Place of Death,
Wintherau
4. Residence,
·
5. Sex, and whether Single, Married, or Widowed,
Married
6. Age,
49 Years,
3 Months,
Days.
7. Color,t
.
8. Occupation,
Consumption
9. Disease or
First or Primary,
Cause of Secondary, (if any,)
Dr. H. I. Soule
Deatlı, 1 By whom certified,
10. Place of Birth, ·
11. Place of Interment, .
12. Name of Father,
·
Samuel Reviveder Wells Maine
14. Name of Mother,
·
15. Birthplace of Mother,
-
Mary Robinson
Wells Maine
Signature of Undertaker or other person making the Return,
0
(Undertaker)
Dated at. Azzz/hora/2
-. , on
fans
186)
* If a Married Woman or a Widow.
+(W.) White. (A ) African. (M ) Mixed White and African If of other Races, specify what
[Be very particular to ñil all Blanks.]
.
Wells OMaine
Winthrop
13. Birthplace of Father,
The Undertaker, or other informant, is requested to report the faets-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred, (or the deceased resided,) having first been obtained, the person having charge of such Interment must FORTHWITHI GIVE NOTICE thereof-or report these facts-to said Clerk. Penalty for neglect, twenty dollars.
Blank forms of Returns may be obtained from the Town Clerk.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
To the Clerk or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased,
Allan S. Grant Male
Date and Place of Death, .
June 29"180 Wildlich
Disease, L First or Primary,
18% fullere
Duration of,*
or Cause of Death,
Secondary, .
franculations
Duration of,
I certify that the above is a true Return, to the best of my recollection and belief.
Name, Professional Title, and Residence,
Dated at Wilthrady fierce 30
18 922
[Be very particular to fill all Blanks.]
* Reckoned to the time of death.
Any Physician having attended a person during his last illness, shall-when requested within fifteen days after the decease of such person-forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can state the same .- [EXTRACT FROM CHAPTER 21 OF THE GENERAL STATUTES, 1859. ]
The attending Physician is requested to make out his Certificate as promptly as possible, for the information and use of the Undertaker, or other person making return of the case to the Town Clerk.
Physicians may obtain BLANK CERTIFICATES from the Town Clerk or Registrar.
Copies of the STATISTICAL NOSOLOGY, adopted for the purposes of Registration, may be obtained on application to the SECRETARY OF TIIE COMMONWEALTHI.
RETURN OF DEATH TO THE CITY REGISTRAR,
CITY HALL, BOSTON.
Date of Death,
usy
9
149
18
80
1/
Name, (ano)
flines.
Color,
Age,
yearf.
month
) days
Place of Death ?
Winthrop.
WARD
..
Street and No.
Residence, 56 Lincoln St Pant Sex, M Single, Married
Occupation,
Wife of
Birthplace, *
2. Widow of ...
Name of Father.
patrick
Name of Mother,
Homenat
Birthplace of Father, * 1, 2 astina
Birthplace of Mother. *
brefand
Cause of
Primary,
Chat Infantino Duration,
Death, S Secondary, .....
Duration, ....
Place of Interment,
Orchester
Date of Interment or Removal,
-July
11
Undertaker or Informant, John Mc Caffrey
Insert Town and State.
..
EGIS TRAR
JUL
380
July 9 th 18,80
James Shiny 1880, aged ories years;
days. Cholera Auf antisoDuration
CAUSE OF Primary,
DEATH.
Sterk
Secondary,
Duration.
Edu Juilliany ILA Physician.
Boston,
fies, that
died on the -9
RO 2
day of July
F BY 10
REAL
months, ED
five.
Rockwell & Churchill, City Printers, 122 Washington St.
OSTON. bis C
-
1580 187
Boston,
Certi es, that Henry Eugene Manley died on the 18th day of July 8 .months, 2.5
188, agal.
years,
days.
CAUSE OF ) Primary, ...
Cholera In faulum Duration.
DEATH. Secondary, Duration.
Edi J. Williamy MA
Physician.
Rockwell & Churchill, City Printers, 122 Washington St.
vvvulicu.
1. Date of Death,
2. Name,
July 18 "1880, Henry 6. Hanley
(Maiden Name),'
male
3. Sex, and whether single. ~ Single Married, or Widowed,
4. Color, t .
White
5. Age, .
Years, ... 8 Months, 25 Days. Cholera Enfantum
6. Disease or
First or Primary
Cause of Secondary (if any)
Death, By whom certified
7. Residence,
8. Place of Death,
9. Occupation, .
10. Place of Birth, . Galón Mace John burtin 11. Name of Father, Chellie Stanley 12. Name of Mother, . 13. Birthplace of Father, . Gnet Pocelou, mace Hubbardeten mace .
14. Birthplace of Mother, .
15. Place of Interment,
Hinthole Town Cemetery Allangere los
Signature of Undertaker or other peroon making the Return,
Dummer Floyd
DATED at. .
Minitrope, on July 19
1880.
* If a Married Woman or Widow.
+ If other than white. (A.) African; (M.) Mulatto; (I.) Indian. If of other Races, specify what. [Be very particular to fill all Blanks.]
·
Jnain St. Winthrop. Sea Show Home mani &t.
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred (or the deceased resided) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof - or report these facts - to said Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
-
₡
Boston, July 27the 1886
This Certifies, that Peter Gallagher died on the 27th day of July 18780, aged 1 years
6 months,
days.
DEATH.
S
Secondary,.
Sayfa
CAUSE OF
Primary,
Cholera Infanhim Duration.
Duration.
Edie Fusilliany M.D. Physician.
Rockwell & Churchill, City Printers, 122 Washington St.
1. Date of Death,
2. Name,
(Maiden Name), *
·Una 2/4/880 Onnie E. Melch
3. Sex, and whether single, Married, or Widowed,
Female
4. Color, t
White
X
Years, ...
8
Months, ..
14
Days.
5. Age,
6. Disease or [
First or Primary
Cause of { Secondary (if any)
Death,
By whom certified
1
as Sea Shore Home
7. Residence,
8. Place of Death, 11
9. Occupation, .
10. Place of Birth, . Talon
11. Name of Father,
12. Name of Mother, .
13. Birthplace of Father, .
14. Birthplace of Mother, . Jemenary 15. Place ef Interment,
Signature of Undertaker person making the Return,
Thomas Welch Many Welch Of John F. B. get John F.10 .. Jon Voiving Somt Drummer Ho
Fond
avner com
DATED al. Winthrop, on aluguel 22% 1880.
* If a Married Woman or Widow.
t If other than white. (A.) African; (M.) Mulatto; (I.) Indian. If of other Races, specify what. [Be very particular to fill all Blanks.]
The Undertaker, or other informant, is requested to report the facts-together with il Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE TIIE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of Town in which the Death occurred (or the deceased resided) having first been obtained, the pers having charge of such Iuterment must FORTHWITH GIVE NOTICE thercof- or report these facts -to 68 Clerk. Peualty for neglect, twenty dollars.
Blauk forms for Returns of Deaths may be obtained from the Town Clerk.
Annie Evelyn Welch. Died aug 21-1880 aged & more-14 days
vural from Winthisje to Roxbury + Mount Hope
witting Boston, ang. 22 1848
Certifies, that anni Evelyn Welch
died on the 2
day of Ing.
18× 80, aged - years, L
S
months,
14 days.
CAUSE OF ) Primary,
Measles
Duration.
DEATH. Secondary, Pneumonia + Drankna Duration.
lwk 2 wks.
Edward T. William Mi. D. Physician
Rockwell & Churchill, City Printers, 122 Washington St.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
To the Clerk or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased,
Date and Place of Death, . ·
Disease,
First or Primary,
Cholera Lul ante. Duration of"
or Cause of Death,
Secondary, .
-
Duration of,
I certify that the above is a true Return, to the best of my recollection and belief.
Name, Professional Title, and Residence,
Dated at
1890.
* Reckoned to the time of death.
[Be very particular to fill all Blanks.]
Bertha Hiller
n
Any Physician having attended a person during his last illness, shall-when requested within fifteen days after the decease of such person-forthwith furnish for registration a certificate of the duration of the last sickness, the discase of which the person died, and the date of his decease, as nearly as he can stato the same .- [EXTRACT FROM CHAPTER 21 OF THE GENERAL STATUTES, 1859. ]
The attending Physician is requested to make out his Certificate as promptly as possible, for the information and use of the Undertaker, or other person making return of the case to the Town Clerk.
Physicians may obtain BLANK CERTIFICATES from the Town Clerk or Registrar.
Copies of the STATISTICAL NOSOLOGY, adopted for the purposes of Registration, may be obtained on application to the SECRETARY OF THE COMMONWEALTH.
www. with or the town in which the Death occurred.
1. Date of Death,
2. Name,
(Maiden Name),*
3. Sex, and whether single. Married, or Widowed.
4. Color, t
5. Age, .
6. Disease or First or Primary ..
Cause of Secondary (if any) Death, By whom certified
7. Residence,
8. Place of Death,
9. Occupation, .
10. Place of Birth, .
11. Name of Father,
12. Name of Mother, .
13. Birthplace of Father, .
14. Birthplace of Mother, .
15. Place of Interment, .
Signature of Undertaker at other person making the Return,
Hermon St Winthrop Harmin St- Minststopa
Hinthope William Hillie mary Millie
London-England Winthrop, Town Cemetery Summer Floyd
DATED at Minthraje, on auquel 30 1870
* If a Married Woman or Widow.
t If other than white. (A.) African; (M.) Mulatto; (I.) Indian. If of other Races, specify what. [Be very particular to fill all Blanks.]
aluguer 29 "1880. Bertha Willie
afemale While
Years, ..
Months, ...
29
... Days.
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
" In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred (or the deceased resided) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof - or report these facts-to said Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
Boston, Sept Q. 18780 This Certifies, that John Mc Cormack died on the 6th day of Sept.
1880, aged. 1 years,
2 months,
-dans.
CAUSE OF ) Primary,.
Cholera Infantum.
Duration.
Juk
DEATH.
Secondary,
Duration
Rockwell & Churchill, City Printers, 122 Washington St.
Edu. T. William M.Physician.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
To the Clerks or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased,
Medic et Histoir
Date and Place of Death, .
Disease, First or Primary,
Duration of,*
16 ching ,
pr Cause
of Death,
Secondary, .
Duration of,
1 days
I certify that the above is a true Return, to the best of my recollection and belief.
Name, Professional Title, and Residence,
1
Dated at Nicitherapy ). 1.1 15%.
IS YO .
[Be very particular to fill all Blanks.]
* Reckoned to the time of death.
#
Any Physician having attended a person during his last illness, shall-when requested within fifteen days after the drecase of such person-forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the date of his decease, as nearly as ho can state the same .- [EXTRACT FROM CHAPTER 21 OF THE GENERAL STATUTES, 1859. ]
The attending Physician is requested to make out his Certificate as promptly as possible, for the information and use of the Undertaker, or other person making return of the case to the Town Clerk.
Physicians may obtain BLANK CERTIFICATES from the Town Clerk or Registrar.
Copies of the STATISTICAL NOSOLOGY, adopted for the purposes of Registration, may be obtained on application to the SECRETARY OF THE COMMONWEALTH.
v JUWI In which .ne Death occurred.
1. Date of Death,
2. Name,
(Maiden Name),
Defet 14 "1880 Nettie et Weetion
3. Sex, and whether single. Married, or Widowed.
tamale
Mhité
4. Color, t
5. Age, .
6. Disease or [ First of Primary
Cause of Secondary (if any)
Death,
By whom certified
7. Residence,
8. Place of Death,
9. Occupation, .
10. Place of Birth, . Gast Belin Ware. 11. Name of Father, Trachburn Melon Hannah 6. Nexton 12. Name of Mother, . 13. Birthplace of Father, . Marchfield mare 14. Birthplace of Mother, . Often Jersey. Winthrop Jour Cemetery 15. Place of Interment, .
Signature of Undertaker esther person making the Return,
Summer Hand
DATED at Monthropa, on Sept 15
1850
* If a Married Woman or Widow.
If other than white. (A.) African; (M.) Mulatto; (I.) Indian. If of other Races, specify what. [Be very particular to fill all Blanks.]
10 .... Years, .. 6 Mouths, ... XI Days.
bor Pleasant Lincoln St Winthrop Map 11
=
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred (or the deceased resided) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof -or report these facts -to said Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
ex of Deceased, Leonard Leonard ( Juntasheures. Llule ........ ace of Death,
11 ec 26 1886
Disease or
cause of Death,
1.). Duration of". lieu , (ai)
I certify that the above is true to the best of my recollection and belief.
ional Title, and Residence,
11.1.
Dated at
IS
* Reckoned to the time of death.
particular to fill all Blanks.]
wit Tuwn in which the Death occurred.
1. Date of Death,
2. Name,
·
1
(Maiden Name),*
December 26 " 1880 Leonard Q. Struktury
3. Sex, and whether single. Married, or Widowed.
Male (Married)
4. Color, t
5. Age, .
H4 Years,
Months, 20 Days.
6. Disease or | First or Primary
Cause of Secondary (if any)
Death,
By whom certified
7. Residence,
8. Place of Death,
9. Occupation,
10. Place of Birth, .
11. Name of Father,
12. Name of Mother, maketi A. Jawklury 13. Birthplace of Father, . Printing, (Point Shirley Finthoje, 14. Birthplace of Mother, . Trinchop Joun Cemetery 15. Place of Interment,
Signature of Undertaker or other person makin! the Return,
Summer Floyd
DATED at
Hinthropa
December 27 180
,
on
* If a Married Woman or Widow.
t If other than white. (A.) African; (M.) Mulatto; (I.) Indian. If of other Races, specify what. [Be very particular to fill all Blanks.]
Winthrope. (Point Shipley) Printhrop, (Point Shirley) 6xfare-Ima Minttrop. (Point Shirley)
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred (or the deceased resided) having first been obtained, the person having charge of such Interment must FORTHWITH GIVE NOTICE thereof - or report these facts -to said Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Name and Sex of Deceased,
Cleverer Tourwill ...
11.
1
Date and Place of Death,
Y
Disease or
cause of Death,
Duration of,“
...
I certify that the above is true to the best of my recollection and belief.
Name, Professional Title, and Residence,
Dated at
IS
[ Be very particular to fill all Blanks.]
* Reckoned to the time of death.
c
جم
RETURN OF A DEATH. To the Clerk of the Town in which the Death occurred.
1. Date of Death,
2. Name, (Maiden Name),
December 3ª 1880 6 Venezer Burrice Jr.
3. Sex, and whether single. Married, or Widowed.
4. Color, t
5. Age, .
6. Disease or ( First or Primary ..
Cause of Secondary (if any)
Death, By whom certified
7. Residence,
8. Place of Death,
9. Occupation, .
10. Place of Birth, .
11. Name of Father, Ebenezer Pourrice
12. Name of Mother, .
13. Birthplace of Father, .
14. Birthplace of Mother, .
15. Place of Interment, .
madison ave Winthrop
madison are Ymathys
starmer
Gast Selon Mass
mary 6. Burriel
mars
Wantthale mare
Minttrofe Torm Cemetery
Signature of Undertaker or other person making the Return,
Summer Floyd
DATED at. Winthrop, on.
December 3" 1× 80,
* If a Married Woman or Widow.
t If other than white. (A.) African; (M.) Mulatto; (I.) Indian. If of other Races, specify what. [Be very particular to fill all Blanks.]
male (Mmmarried While 34 Years, 8 Months, 16 Days.
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death-to the Town Clerk, BEFORE THIE INTERMENT.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the Town in which the Death occurred (or the deceased resided) having first been obtained, the person having charge of such Interment must FORTHWITHI GIVE NOTICE thereof- or report these facts -to said Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deathis may be obtained from the Town Clerk.
VIU.
RETURN OF A DEATH. To the Clerk of the Town in which the Death occurred.
1. Date of Death,
2. Name,
April 6 1881 Susan Hay
3. Sex, and whether single, Married, or Widowed.
Finale.
(Nidow)
Milé
4. Color, t
5. Age, .
74 Years,
Months,
13 Days.
6. Disease or [ First or Primary
Cause of Secondary (if any)
Death, 1 By whom certified
7. Residence,
8. Place of Death,
9. Occupation,
10. Place of Birth, .
11. Name of Father,
Daniel ét'ay.
12. Name of Mother, . Ruth R Say
13. Birthplace of Father, . Westboro made
14. Birthplace of Mother, .
15. Place of Interment,
Sudbury mars Southlow Mark
Signature of Undertaker or other person making the Return,
DATED at ..
Winthrop
On.
188%.
* If a Married Woman or Widow.
t If other than white. (A.) African; (M.) Mulatto; (I.) Indian. If of other Races, specify what. [Be very particular to fill all Blanks.]
Pulnam St Winthrop
maes
Summerfloyd
(Maiden Name),
The Undertaker, or other informant, is requested to report the facts-together with the Physician's Certificate of the Causes of Death -to the Town Clerk, BEFORE THE INTERMENT.
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