Town of Winthrop : Record of Deaths 1933, Part 95

Author: Winthrop (Mass.)
Publication date: 1933
Publisher:
Number of Pages: 520

USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1933 > Part 95

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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.

State cause for which surgical operation was undertaken.

Bronchopneumonia: If primary cause, write the word "primary"; if secondary, give primary cause.

Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, mis- carriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.

RM R-301A

SurfaIR (County)

Winthrop (City or Tow) PLACE OF DEATH No. 20 Wilshire

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

248

Registered No. (If death occurred in a hospital or institution, { give its NAME instead of street and number)

Elizabeth O'Rourke

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

(a) Residence.

No.

20 Wilshire

St.,

Ward,

(Usual place of abode)

Length of residence in city or town whare death occurred

yrs.

mos.

days .

How long in U. S., if of foreign birth?

yrs.

mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE

(write the word)

married

(Give maiden name of wife in full)

O'ROURKE

(Husband's name in full)

If less than 1 day Hours. Minutes

housewith

11 Total time (years) spent in this occupation

FATHER Peter d'RouxE Gillis

14 BIRTHPLACE OF

FATHER (City)

nova Scotia.

15 MAIDEN NAME

OF MOTHER

Elsbeth mac Phee

16 BIRTHPLACE OF MOTHER (City) nova Scotia. (State or country)

filed I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: y. m. D. but trig A (Signature of Agent of Board of Health of other) Health fleet 12/30/33 (Official Designation) (Date of Issue of Permit)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

DEATH

(Month)

(Day)

(Year)

I HEREBY CERTIFY, That I attended deceased from

19 23

1 1

, 19

3 3

I last saw h .. . alive on ... 19 death is said

to have occurred on the date stated above, at.

7.50 P.m.

The principal cause of death and related causes of importance in order of onset were as follows:

Dateofonset

Carcinomacore 2

3 1929

1.V

Contributory causes of importance not related to principal cause:

Name of operation

Date of

What test confirmed diagnosis?

Was there an autopsy?

20 Was disease or injury in any way related to occupation of deceased? If so, specify./

(Signed)

M. D.

21 PLACE OF BURIAL,

CREMATION OR REMOVAL

Holy Cross Walden

(Cemetery)

(City or town)

DATE OF BURIAL

DEC. 31. 1933

22 NAME OF

UNDERTAKER

Murray + Murray

ADDRESS

345 Broadway REVERE

Received and filed

.19

(Registrar)

1 2 FULL NAME 3 SEX temale 4 COLOR OR RACE white MARRIED WIDOWED or DIVORCED 5a If married, widowed, or divorced HUSBAND of (or) WIFE of James 6 IF STILLBORN, enter that fact here. 7 AGE 68 Years Months .Days 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 OCCUPATION! year) (State or country) 13 NAME OF (State or country) PARENTS 17 Pater Jordan Informant (Address) is very important. See instructions and extracts from the laws on back of certificate. information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION 75m-2-'30. No. 7997-a N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of 12 BIRTHPLACE (City) nova Scotia

St.,

Ward

(If U. S. War Veteran, specify WAR) 214

(If nonresident, give city or town and state)

Revised United States Standard Certificate of Death

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 occupation prior to illness. If the deceased had retired from business, report the 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 in answer to Question 8 and own home in answer to Question 9. 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 what- ever write none.

To be complete, an occupation return must state:

8 .- The trade, profession, or particular kind of work done.

9 .- The industry or business in which the work was done.

10 .- The month and year the deceased last worked at the occupation. 11 .- The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms as "employee," "worker," "operative," etc. Find out the parti- cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general terms as "store, " "factory, " "mill. " 11," etc. State the particular kind of store, factory, mill, etc., as grocery store, soap factory, cotton mill, etc.

Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as civil engineer, mechanical engineer, mining engineer, stationary engineer, etc. Avoid the term "laborer" when a more precise statement of the occupation can be secured. Do not use the word "mechanic, " but give the exact occupation, as carpenter, painter, machinist, etc. Distinguish carefully between retail merchants and wholesale merchants. A person who sells goods should be called a salesman and not a clerk.

Statement of cause of death .- Cause of death 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 earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause. Under contributory causes of importance not related to principal cause, name other important diseases.

Example

The principal cause of death and related causes[ of importance in order of onset were as follows: Arteriosclerosis

Date of onset

1915

Chronic interstitial nephritis

1921

Cerebral hemorrhase

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 be' ief 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 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 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.

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.

RM R-301 A

Suffolk

The 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 249 or its Agent.

2375

Registered No ..

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

(If U. S.

War Veteran,

specify WAR,

245

(a) Residence.

No.

(Usual place of abode)

Length of residence in city or town where death occurred

mos.

days.

How long in U. S., if of foreign birth?

yrs.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX.

4 COLOR OR RACE

5 SINGLE

MARRIED

WIDOWED

or DIVORCED

(write the word)

married

5a If married, widowed, or divorced

HUSBAND of

Falkh Darthey Sargent

(or) WIFE of

(Husband's name in full)

6 IF STILLBORN, enter that fact here.

AGE 71 Years Months Days

If less than 1 day

Hours

Minutes

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 mil Housemade saw mill, bank, etc.

10 Date deceased last worked

this occupation (month

11 Total time (years)

spent in this occupation 50 year) Sec 1934

12 BIRTHPLACE (Cit) Holderness. (State or country) New Hampshire

13 NAME OF

FATHER

Henry Smith

14 BIRTHPLACE OF

FATHER (City)

Plymouth.

(State or country)

15 MAIDEN NAME OF MOTHER

Qualieth Smith

16 BIRTHPLACE OF

MOTHER (City)

ashland

(State or country) Hur Hampshire

mr. Ralph & Sargent

Informant (Address) 145 Bowdoin

I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Von Nehaldievs (Signature of Agent of Board of Health or other)

(Official Designation) 7"(Date of Issue of Permit)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

DEATH

(Month)

(Day)

( Year)

19 I HEREBY CERTIFY, That I attended deceased from 12-

I last saw h.twee

alive on ... - 12-29.

, 19.3.8 .. , death is said

m. to have occurred on the date stated above, at The principal cause of death and related causes of importance in order of onset were as follows:

Lete cf Onset IMPORTANT

sente Ilitation of Heart

2/29

Contributory causes of importance not related to principal cause:

Diabetes ty ellitus

2 yes

Name of operation

What test confirmed diagnosis?

Date of

Was there an autopsy?

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

If so, specify.

Huren aut elli

(Signed)

, M. D.

(Address)

Date 12/24

1933.

21 PLACE OF BURIAL, Locust Grove, n.H. (Cemetery)

(City or town) 1934

DATE OF BURIAL

22 NAME OF

UNDERTAKER

Plainly Inc

ADDRESS

Received and filed

Doc. 30, 1937.

(Registrar)

MARGIN RESERVED FOR BINDING

7 OCCUPATION. 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 75m-5-'32. No. 5469 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of PARENTS

PLACE OF DEATH

(County) Stanthrop

(City or Town) 145 Bowdown No.

St.,

Ward

2 FULL NAME

Winnie Ladd Sargent

(If deceased is a pratried, widowed of divorced woman, give also maiden name.)

145

Bowdown St ...

....

Ward,

(If nonresident, give city or town and state)

mos.

days.

,193.3., to

12-29

19.3 3

at Home

Revised United States Standard Certificate of Death

To be complete, an occupation return must state:

8 .- The trade, profession, or particular kind of work done.

9 .- The industry or business in which the work was done.

10 .- The month and year the deceased last worked at the occupation.

11 .- The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms as "employee." "worker. "" "". "operative," etc. Find out the parti- cular kind of work done and return that, as spinner. weaver, etc.

In stating the industry or business, avoid the use of such general terms as "store." "factory," "mill." etc. State the particular kind of store, factory, mill, etc., as grocery store, soap factory, cotton mill, etc.

Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as civil engineer, mechanical engineer, mining engineer, stationary engineer, etc. Avoid the term "laborer" when a more precise statement of the occupation can be secured. Do not use the word "mechanic, " but give the exact occupation, as carpenter. pointer, machinist, etc. Distinguish carefully between retail merchants and wholesale merchants. A person who sells goods should be called a salesman and not a clerk.

Example

The principal cause of death and related causes of importance in order of onset were as follows:

Date of onset

Arteriosclerosis

Chronic interstitial nephritis

1021

Cerebral hemorrhage

July 5. 1927

Contributory causes of importance not related to principal cause:

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 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 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 such a permit for the removal of a human body. not previously interred, trom one town to another within the common- wealth 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 re- moval; 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 removal of such body has been sooner obtained hereunder. If the death certificate contains a recital, as re- quired 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 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., as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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.

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.

(3) Medical Examinera 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.

RM R-302

SUFFOLK

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

BOSTON

(City or town making return)

Registered No .. 10965

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

2 FULL NAME

George M

Stilwell

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

specify WAR)

(a)

Residence. No.

(Usual place of abode)

147Cottage .. Park Rd

St.,.

.......

Ward,

.Winthrop

(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

5 SINGLE

MARRIED

WIDOWED

or DIVORCED

(write the word)

married

5a If married, widowed, or divorced

HUSBAND of

Victoria Adelaide

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

6 IF STILLBORN, enter that fact here.

AGE

Years

Days

If less than 1 day Hours Minutes

OCCUPATION|

8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc ..

salesman

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 .....

34 yr

12 BIRTHPLACE (City)

(State or country)

13 NAME OF FATHER

Jerome Stilwell

14 BIRTHPLACE OF

FATHER (City)

PARENTS

15 MAIDEN NAME

OF MOTHER

16 BIRTHPLACE OF MOTHER (City) (State or country)

Informant

Harry H.Stilwell

(Address)

A TRUE COPY.

ATTEST:

James J. Mulvey

(Registrar of city dertown where death occurred

DATE FILED

Jan

19 34

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

DEATH

Dec 30 1933

(Month)

(Day)

(Year)

19 I HEREBY CERTIFY, That I attended deceased from

Dec

.27

19.33, to.

.Dec

.30

19 ... 33

.. 30 19 ... 33, death is said I last saw him .... alive on Deo

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

The principal cause of death and related causes of importance in order of onset were as follows:

Dateofonset

12/29/33 edema ... of .. lungs

Contributory causes of importance not related to principal cause: general .. arteriosclerosis ....

Name of operation

What test confirmed diagnosis?

Date of

Was there an autopsy?

20 Was disease or injury in any way related to occupation of deceased? If so, specify

(Signed)

HA Kelly

M. D.

(Address)

Boston

Date

12/3169 .33.

21 PLACE OF BURIAL,

CREMATION OR REMOVAL

Winthrop

(Cemetery) (City of town)

DATE OF BURIAL

Jan

19.34

22 NAME OF

UNDERTAKER

C ... R. Bennison

ADDRESS

Winthrop

.... Received and filed JAN 10 1534

"Registrar of City or Town where deceased resided)

(County)

BOSTON

(City or Town)

No. Hotel .. Manger.

St.,

Ward

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-2-'30. No. 7997-1

Months

Dee 26/33

Belvidere

(State or country) unknown

(If U. S.

War Veterans,

250

ORM R-302

L'idu lesex

(County)

(City or Town) Holy Ghost Hospital No.

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

(City or town making return)

Registered No ....

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

2 FULL NAME

Michael & Delivers

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

(a)

Residence. No.

6 Revere Ji.

St.,

Ward,

(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.

dayı.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE

MARRIED

WIDOWED

or DIVORCED

Married

(Month)

(Day)

(Year)

19 I HEREBY CERTIFY, That I attended deceased from

19 .. "." " .. to.

last saw h

........

... alive on

Dec 11

1923

death is said

to have occurred on the date stated above, at.

1.15 1

The principal cause of death and related causes of importance in order of onset were as follows:

Datesfonset

mixer on spinal cord

₣

12 BIRTHPLACE (City)

20010:

(State or country)

13 NAME OF

Paul Desimone

FATHER

14 BIRTHPLACE OF

FATHER (City)

PARENTS

(State or country) Italy

15 MAIDEN NAME

OF MOTHER

Angeline Naah

16 BIRTHPLACE OF MOTHER (City) (State or country) Maine

17 Agnes Desimone

Informant

(Address)

A TRUE COPY.

Frederick. H. Burke

Dec 13 1933

ATTEST:

(Registrar of city or town where death occurred)

DATE FILED 19

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

DEATH

Doc.19, 1933

5a If married, widowed, or divorced HUSBAND of

Che3 Thing

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

6 IF STILLBORN, enter that fact here.

7 41

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 .. 9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.

achiriut

10 Date deceased last worked at

11 Total time (years)

spent in this

occupation .....

this occupation (month and.

year) ..

Contributory causes of importance not related to principal cause:

Name of operation

Date of

What test confirmed diagnosis?

Was there an autopsy?

20 Was disease or injury in any way related to occupation of deceased? If so, specify.

(Signed)

(Address)

81. Dana Jve Cami. Daten . Im

M. D.

.19 AM ......

21 PLACE OF BURIAL,

CREMATION OR REMOVAL. COM. SUC:

DATE OF BURIAL

Dec. 15. 1933

(Cemetery) (City or towa) 19

22 NAME OF

UNDERTAKER

ADDRESS

1400 Dorchester Ve.

Received and filed ...

JAN 1-9 1934

(Registrar of City or Town where deceased resided)

important.

50m-2-'30. No. 7997-d

PLACE OF DEATH

St.,

Ward

(If U. S.

War Veteran,

specify WAR)

251

(write the word)

AGE

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Town of Winthrop : Record of Deaths 1933, Part 95

Author: Winthrop (Mass.) Publication date: 1933 Publisher: Number of Pages: 520

Author: Winthrop (Mass.)
Publication date: 1933
Publisher:
Number of Pages: 520