USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1931 > Part 70
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Date of onset
Arteriosclerosis
1915
Chronic interstitial nephritis
1021
Cerebral hemorrhage
July 5, 1927
Contributory causes of importance not related to principal cause:
...
In a group of causes containing the principal cause and related causes, the causes should be given in the order of onset, so that in a group of three causes the principal cause may appear in either first, second, or third position. The principal cause in the above example happens to be the second cause given.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth- with, 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 required 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.
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 Juried, 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 satis- factory 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 physician 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 required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. 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 state- ment 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., as amended.
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence .... Gen. Laws, Chap. 38, Sec. 6.
.... He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residence, if known; otherwise a description as full as may be, with the cause and manner of death .- Gen. Laws, Chap. 38, Sec. 7.
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 have the care of the ceme- tery or burial ground in which the interment is made .. .. Chap. 114, Sec. 46, G. L. as amended.
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 un- related to any form of injury, have died without recent medical attend- ance 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.
FORM R-302
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
1
Boston
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
6771
(If death occurred in a hospital or institution,
Ward
give its NAME instead of street and number)
2 FULL NAME
Grace E Stone
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
90 Lincoln
.St.,
...........
Ward,
Winthrop, ... Mass.
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
days.
How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
August
4.
193ª
(Month)
(Day)
(Year)
X, That I attended deceased from
19 I HEREBY CERTIF August 3,
31
August
4,
19
31
1 last saw h
eralive on
August
4.
, 19.31
death is said
to have occurred on the date stated above, at:
4:20₽
m.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
Fibrous ... pleuritis
2
Stones in common duct
? mos.
Partial collapse of rt. lower lobe
Contributory causes of importance not related to principal cause:
?
Name of operation
Date of
What test confirmed diagnosis?
Was there an autopsy? Yos
20 Was disease or injury in any way related to occupation of deceased?
If so, specify.
(Signed)
C., L. Clay,
M. D.
(Address) .Boston, Mass.
Date
8/4/ 19 31
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Old Green Hartford, Com
(Cemetery)
(City or town)
DATE OF BURIAL
19
August
7
31
22 NAME OF
UNDERTAKER
Walter T. White
ADDRESS
Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
C Sullivan (Signature of Agent of Board of Health or other)
Aug. 4, 1931
1 2/ 193
5 SINGLE
(write the word)
Female
4 COLOR OR RACE
White
MARRIED
WIDOWED
or DIVORCED Married
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
Charles G. Stone
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
AGE
7 56 9 Months Days
If less than 1 day Hours Minutes
OCCUPATION|
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
Housewife
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc .. .
10 Date deceased last worked at this occupation (month and year) .
11 Total time (years)
spent in the
occupation26 yrs
12 BIRTHPLACE (City)Hartford ... Conn. (State or country)
13 NAME OF FATHER Edgar S. Fox
PARENTS
14 BIRTHPLACE OF FATHER (City)
(State or country) Conn
15 MAIDEN NAME OF MOTHER
.
16 BIRTHPLACE OF MOTHER (City) (State or country) Conn
17 Husband
Informant
(Address)
important.
50M-11-'29. No. 7180-b
PLACE OF DEATH
Suffolk (County)
No.
(City or Town) Peter Bent Brigham Hospital
.St.
(If U. S. War Veteran, specify WAR)
182
(If nonresident, give city or town and state)
Received and filed.
OCT2 4 1931
, "ugust
7,
31
19
3 SEX
MARGIN RESERVED FOR BINDING
Years 12
19
to
Trace 6 Stone Cung 4, 1931
FORM R-302
MARGIN RESERVED FOR BINDING
1 2 FULL NAME 3 SEX m. (or) WIFE of 7 OCCUPATION 13 NAME OF FATHER 14 BIRTHPLACE OF FATHER (City) (State or country) PARENTS important. N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE saw mill, bank, etc. 50M-11-'29. No. 7180-b
PLACE OF DEATH
Suffolk County) Boston (City or Town) Boston City Hospital St., No.
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Boston (City or town making return)
Registered No
6797
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Frederick It Sanders
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence.
No ..
34 Crescent St
.. St.,.
.....
Ward,
specify WAR)
Winthrop, mass
(If nonresident, give city or town and state)
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
days.
How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
ou.
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
m.
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
Helen Dunbar
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
AGE 53 Years 1 Months 2 + Days
If less than 1 day
Hours
Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc.
Stock Clerk
9 Industry or business in which
, as silk
O. S Rubber Co
10 Date deceased last worked at
11 Total time (years)
this occupation (month and
year)
apr. 1931
spent in this,
occupation 24 yrs
12 BIRTHPLACE (City)
Boston
(State or country)
mase
George M. Sanders
Boston
mars
15 MAIDEN NAME
OF MOTHER
annie 6. moore
Boston
16 BIRTHPLACE OF MOTHER (City) (State or country) mass
17 Chas E Sanders
Informant (Address) E. Braintree mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: I. F. G
(Signature of Agent of Board of Health or other) 8/6/31
(Official Designation) (Date of of Pern
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
august
4
1931
(Year)
(Month)
(Day)'
19 I HEREBY CERTIFY, That I attended deceased from
1/21
1931, to.
8/4
1951
I last saw himmalive on
8/4
,1931, death is said
to have occurred on the date stated above, at.
11:31 Pm.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
Cerebral hemorrhage stwko
Broncho sne
umonia
Contributory causes of importance not related to principal cause:
Date of
Name of operation
What test confirmed diagnosis?
Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased?
If so, specify.
OF Weich
(Signed)
. M. D.
(Address
Boston City Hoop Date
8/5
19 .3.1.
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Start Will Hingham
(Cemetery)
(City(or town)
DATE OF BURIAL
august 7, 1931
22 NAME OF
Q + & F. Gleason
UNDERTAKER
ADDRESS
worchester, mass
august 7, 1931
Received and filed
OCT 24 1931
T copy HATTEST. (Readtrar)
AT 24 1937
Ward
(If U. S.
War Veteran,
183
Frederick & Sanders Cmq + 1931
- -
ORM R-305
SUFFOLK
(County)
BOSTON
(City or Town) No. .... .MASS .... GENERAL ... HOSP.I.T.AL
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY · DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
6939
(If death occurred in a hospital or institution,
Ward
give its NAME instead of street and number)
2 FULL NAME
GERTRUDE C FLATER.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(LE U. S.
War Veteran,
specify WAR)
18.1
(a)
Residence. No.
(Usual place of abode)
150 HERNON
St.,
.Ward,
WINTHROP, MASS.
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
mos.
days. How long in U. S., if of foreign birth? yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
WHITE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
SINGLE
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE . (Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 3 Years Z Months
10 Days
If less than 1 day Hours Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc. 9 Industry or business in which work was done, as silk mill, saw mill, bank, etc ..
10 Date deceased last worked at
this occupation (month and
year) ...
11 Total time (years)
spent in this
occupation ..
12 BIRTHPLACE (City)
(State or country)
MASS.
13 NAME OF
FATHER
ALBERT F FLATER,
14 BIRTHPLACE OF FATHER (City) (State or country)
CHELSEA,
MASS
15 MAIDEN NAME
OF MOTHER
GERALDINE A FITZGERALD,
16 BIRTHPLACE OF MOTHER (City) BOSTON, (State or country) MASS.
17 ALBERT F FLATER, Informant (Address) WINTHROP, MASS.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: H FR.
(Signature of Agent of Board of Health or other)
AUG. 11. 1931
(Official Designation)
(Date of Issue of Permit)
2V 193
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
AUGUST 9, 1931
(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, state fully)
POISONING BY LEAD INCIDENTAL TO THE
GNAWING OF PAINTED SURFACE.
(ACT OF CHILDHOOD-PICA)
20 If death was due to external causes (VIOLENCE) fill in the following :
Accident,
Suicide or
Homicide ?
Date of injury
19
Where did injury occur ?
(City or town and State)
Manner of
Injury
Nature of
Injury
21 Was disease or injury in any way related to occupation of deceased?
If so, specify.
GEORGE B MAGRATH,
(Signed)
M. D.
(Address)
MED.Ex. SUFFOLK COate 8/ 10/ 19 3.1.
22 PLACE OF BURIAL,
CREMATION OR REMOVAL
HOLY CROSS. MALDEN.
(Centra. 11, 1931
yfor town)
DATE OF BURIAL
19
23 NAME OF
UNDERTAKER
M J KELLY,
ADDRESS 11 MERIDIAN ST, EB.
Received and filed.
OCT 24 1931
AUG. 13, 131 Inch 19
A TRUE COPY, ATTESTI
(Registrar)
1
PLACE OF DEATH
MARGIN RESERVED FOR BINDING
25 M-11-'29. No. 7180-d
WINTHROP
PARENTS
(write the word)
FEMALE
.St.,
Gertrude
+ later
Clg. 9, 1931
ORM R-305
SUFFOLK (County)
BOSTON
(City or Town)
No.
BOSTON CITY HOSPITAL
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON (City or town making return)
Registered No. 6929
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
VIRGINIA BRYANT,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
73. CRYSTAL.CAVE.
St.,
Ward,
WINTHROP ,MASS
(Usual place of abode)
Length of residence in city or town where death occurred yrs.
mos.
days. How long in U. S., if of foreign birth? yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
FEMALE
4 COLOR OR RACE
WHITE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
MARRIED
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
HILLARD BRYANT
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 22
Years Months Days
If less than 1 day Hours Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
NONE
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc ...
AT HOME
10 Date deceased last worked at
this occupation (month and
year) .
11 Total time (years)
spent in this
occupation ..
12 BIRTHPLACE (City)
QUINCY,
(State or country)
MASS.
13 NAME OF
FATHER
EZIO SERRANI,
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country) ITALY
15 MAIDEN NAME
OF MOTHER
LAURA MARAVIGLIA
16 BIRTHPLACE OF MOTHER (City) (State or country)
QUINCY,
MASS.
17 JOSEPH MARAVIGLI, Informant LYNN
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
A .. E ... C.
(Signature of Agent of Board of Health or other)
AUG. 10, 1931
(Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
AUGUST 10, 1931
(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, state fully) GAS BACILLUS (B.WELCH'S ) INFECTION
FOLLOWING ABORTION.
20 If death was due to external causes (VIOLENCE) fill in the following : Accident
Suicide or
Homicide ?
Where did injury occur ?
(City or town and State)
Manner of
Injury.
Nature of
Injury
21 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
TIMOTHY LEARY,
(Address)
MED. EXAMINER
Date
8/10/931
22 PLACE OF BURIAL,
CREMATION OR REMOVAL
MT ..... WOLLASTON, QUINCY
(Cemetery)
City or town)
DATE OF BURIAL
23 NAME OF
UNDERTAKER JOHN E DONOVAN,
4 . ADDRESS LYNN, MASS.
Received and filed. OCT 24 1931
AUG. 12, 931 A. Mucho
A TRUE COPY; ATTEST:
(Registrar)
1
MARGIN RESERVED FOR BINDING
25 M-11-'29. No. 7180-d
1
PLACE OF DEATH
St.,
..... Ward
(If U. S. War Veteran, specify WAR)
185
(If nonresident, give city or town and state)
(write the word)
(Give maiden name of wife in full)
Date of injury
AUG 6, 193119
M. D.
AUG. 11, 1931
19
(Address)
Virginia Bryant aug. 10, 1931
ORM R-302
Suffolk
(County)
Boston
(City or Town) No. Carney Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Boston
(City or town making return)
6930
Registered No.
(If death occurred in a hospital or institution,
St.,
Ward
give its NAME instead of street and number)
2 FULL NAME
John H. Magee
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence.
No.
26 .. Beal
St.,.
Ward,
.Winthrop .... Mass.
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
18 DATE OF
DEATH
August
10,
1931
(Month)
(Day)
(Year)
5a If married, widowed, er divorced
HUSBAND of
Mgfive "Diyepmname of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 70 Years 7- Months .. O .Days
If less than 1 day Hours Minutes
OCCUPATION!
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc ..
Teamster
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc .... Express Co.
10 Date deceased last worked at this occupation (month and year)
11 Total time (years)
1920
spent in this occupation 20 yrs.
12 BIRTHPLACE (City)
Boston, Mass
(State or country)
13 NAME OF FATHER John Magee
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country) Canada
15 MAIDEN NAME
OF MOTHER
May Baker
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Informant (Address) Quincy, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: H FR
(Signature of Agent of Board of Health or other) Aug. 10, 1931 (Date of Issue of Permit) UST 2
(Official Designation)
A TRUE COPY,"ATTEST: (Registrar)
1
Tracheotomy (reason unknown)
1898
F B in trachea
4 yrs.
Bronchiectasis
Lung abscesses (Multiple)
2 wks.
Contributory causes of importance not related to principal cause:
?
Arteriosclerosis
Chr. Myocarditis
?
Name of operatiRemovalofFB
Date of 8/8/31 ..
What test confirmed diagnosis? Was there an autopsyYes ...
20 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
H È Hedberg,
. M. D.
(Address)
Carney Hospital
Date.
8/10/ 31
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Mt. Wollaston
Quincy
DATE OF BURIAL
Aufgust
12 (City or town)3 1
19
22 NAME OF
UNDERTAKER
John Hall,
ADDRESS
Quincy, Mass.
Received and filed ....
18 .August.
.12,
19.3.1 ..
1
PLACE OF DEATH
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE MARGIN RESERVED FOR BINDING
important.
50M-11-'29. No. 7180-b
LucyPowers
19 I HEREBY CERTIFY, That I attended deceased from
August
2
,19 31 to August 10, 1931
I last saw h
imalive on ...
August
10
19 ........ death is said
to have occurred on the date stated above, at.S. m.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateefenset
MEDICAL CERTIFICATE OF DEATH
(write the word)
(If U. S. War Veteran, specify WAR)
186
(If nonresident, give city or town and state)
John & magers aug. 10,19.
ORM R-305
PLACE OF DEATH
Suffolk (County) Boston
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Boston (City or town making return)
Registered No 7677
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
187
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence.
No. 54 Locust
(Usual place of abode)
Length of residence in city or town where death occurred
JrS.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word) om.
5a If married, widowed, or divorced HUSBAND of ÖTelen fundgreat (Give maiden name of wife in full
(ar) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
AGE
7 5 4 4 Years Months Days
8
If less than 1 day Hours Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner sawyer, bookkeeper, etc ...
Painter
9 Industry or business in which work was done, as silk mill Housepainter saw mill, bank, etc.
10 Date deceased last worked at
11 Total time (years)
this occupation
year) ..
(month auchan 31
spent in this
Occupation 3.5. 2020
12 BIRTHPLACE (City)
(State or country)
Sweden
13 NAME OF
FATHER
Johan Petersen
PARENTS
(State or country)
15 MAIDEN NAME OF MOTHER Johanna -
16 BIRTHPLACE OF MOTHER (City) (State or country)
Sweden
17 Informant (Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: a E. C.
(Signature of Agent of Board of Health or other) 9/10/31
(Date of Issue of Permit)
OCT 24 1931
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH September 8 1931
(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, state fully) Bilateral lobar pneumonia Cedema of brain Recent fractured ribs ue in IF aund un ia
20 If death was due to external causes (VIOLENCE) fill in the following : Accident, Suicide or Homicide ?
Date of injury
19
Where did
injury occur ?
Boston, Mass
Manner of
Injury
Nature of Injury
7
-
21 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
2 Buckley
. M. D.
(Address)
Boston, mais Date
9.19
19 31
22 PLACE OF BURIAL,
mt Hake Boston
(Cemetery)
(City or town)
9/10
19 31
DATE OF BURIAL
23 NAME OF
UNDERTAKER
@ O. Nordling
ADDRESS
Boston, mais
9/12 1931.
Received and filed
OCT 24 1931
A TRUE COPY, ATTEST:
25 M-11-'29. No. 7180-đ
1
City or Town) NoPeter Bent Brigham Woord
Ward
(If U. S. War Veteran, specify WAR) Winthrop mass
St., ..
....
.Ward,
(If nonresident, give city(or town and 'state)
MARGIN RESERVED FOR BINDING
14 BIRTHPLACE OF FATHER (City) Sweden.
(City or town and State)
1
Deonice home)
(Official Designation)
Carl G. Petersen
Sarl &. eleven Dept. 8, 1931
ORM R-302
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE MARGIN RESERVED FOR BINDING
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