USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1937 > Part 86
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(Signed)
, M. D.
(Address)
M J Rhees
Mass Gen Hosp
Date 9/37
19 3
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Winthrop
Winthrop
(City or town)
DATE OF BURIAL
(Cem.uter 9/23/37 19 3
22 NAME OF
UNDERTAKER
C R Bennison
ADDRESS Winthrop
Received and filed
NO9-24 1937
19
(Registrar of City or Town where deceased resided)
1
PLACE OF DEATH
SUFFOLK (County) BOSTON
(City or Town)
Mass Gen Hosp
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON (City or town making return)
Registered No.
8553
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
James Gray
(If deceased is a married, widowed or divorced woman, give also maiden name.)
specify WAR)
(a)
Residence. No.
(Usual place of abode)
39 Hutchinson
.St.,
Ward, ... Winthrop
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yTs.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX M
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Marr
5a If married, widowed, or divorced
Jane
Doig
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 39
17
If less than 1 day Hours Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
Trucking
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
self
10 Date deceased last worked at this occupation (month and year)
9/18/37
11 Total time (years) spent in this occupation.
5
12 BIRTHPLACE (City)
(State or country)
Scotland
13 NAME OF
FATHER
14 BIRTHPLACE OF FATHER (City)
PARENTS
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF MOTHER (City) (State or country)
17 Informant (Address)
Thomas G Doig bro-in-law
No.
St.,
Ward
(If U. S.
War Veteran,
225
Date of
8:23a
m.
Years Months Days
1
I
:
M R-302
PLACE OF DEATH
SUFFOLK (County)
(City or Town) No. 653 Walk Hill St- Home
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON (City or town making return) 8714
Registered No
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Mary Baxter
(If deceased is a married, widowed or divorced woman, give also maiden name.)
10 Highland Av
St.,.
Ward,
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yTS.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Wid
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
George Baxter
(Husband's name in full)
Months
Days
If less than 1 day Hours Minutes
Housewife
saw mill, bank, etc. at home
/35
11 Total time (years)
spent in this
occupation.
-
13 NAME OF
FATHER
William Boyce
15 MAIDEN NAME
OF MOTHER
Louise Garford
England
17
Mrs N C Haydon
dau.
DATE OF BURIAL
ATTEST:
Della Ofeditions Quinte
(Registrar of city or town where death occurred)
9/29/37
DATE FILED 19.3
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Sept 24/37
193
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
9/1/37
.,19 ......
to
9/24/37
19 .. 3.
I last saw h
er
9/24/37
to have occurred on the date stated above, at. 1 .P.m. The principal cause of death and related causes of importance in order of onset were as follows:
chronic myocarditis
arteriosclerosis
Dateofonset
---
--
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
(Signed)
G H Scott
(Address)
Date
9/25
M. D. 19 3.37
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Winthrop Winthrop
(City or town)
(Cemetery)
9/27/37
19 3
22 NAME OF
UNDERTAKER
R H White
ADDRESS Winthrop
Received and filed
-
19
(Registrar of City or Town where deceased resided)
1
BOSTON
(a)
Residence. No ..
(Usual place of abode)
3 SEX
F
4 COLOR OR RACE
W
(or) WIFE of
6 IF STILLBORN, enter that fact here.
7
81
6
7
AGE
Years
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,
10 Date deceased last worked at
this occupation (month and
OCCUPATION
year) ..
12 BIRTHPLACE (City)
(State or country)
Eng løn d
14 BIRTHPLACE OF
FATHER (City)
16 BIRTHPLACE OF
PARENTS
MOTHER (City)
(State or country)
Informant
(Address)
A TRUE COPY
tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
important.
OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
50m-2-'30. No. 7997-đ
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa-
(State or country)
Eng Im d
St.,
Ward
(If U. S.
War Veteran,
220
specify WAR)
Winthrop
19
death is said
R-302
1
BOSTON
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON (City or town making return) 8951
Registered No.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
Mary L McGlincey
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
specify WAR)
(a)
Residence. No.
(Usual place of abode)
19 Charles
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
F
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Marr
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Giye maiden name of wife in full)
John J MCGlincey
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 55 5
14
If less than 1 day
Hours
Minutes
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
H usewife
10 Date deceased last worked at
this occupation (month and
year)
12 BIRTHPLACE (City)
(State or country)
Nova Scotia
13 NAME OF
FATHER
14 BIRTHPLACE OF FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
AnnaChrow
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
17
Tufermant
(Address)
husband
A TRUE COPY
ATTEST:
Huda Ofedition duinte
(Registrar of city or town where death occurred)
DATE FILED
10/7/37
193
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
9/23/37
19
I last saw h
er
alive on
10 /3/37
19 .. , death is said to have occurred on the date stated above, at 12 : 0.5p. The principal cause of death and related causes of importance in order of Dateofonset yra .. onset were as follows: gen arteriosclerosis with cardiac hypertrophy pulmonary infarets
Contributory causes of importance not related to principal cause:
Name of operation
What test confirmed diagnosis?
Date of
Was there an autopsy?
yes
20 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
W B Osgood
M. D.
(Address)
P Bent Brigham H.
Date
10/3
19 3
37
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Winthrop Winthrop
DATE OF BURIAL
19 3
22 NAME OF
UNDERTAKER
R H White
ADDRESS
Winthrop
Received and filed TIV 21 198+ 19
(Registrar of City or Town where deceased resided)
important.
50m-2-'30. No. 7997-đ
PARENTS OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very OCCUPATION
PLACE OF DEATH
SUFFOLK (County)
No.
(City or Town) Peter Bent Brigham Hosp
St.,
Ward
(If U. S.
War Veteran,
227
Oot 3/37
193
., to
10/3/37
19 .. 3
AGE
Years
Months
Days
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
at home
11 Total time (years)
spent in this
occupation
Alexander MacPherson
Scotland
Cemetery) 10/6/37
(City or town)
1
R-302
PLACE OF DEATH
SUFFOLK (County) BOSTON
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
9012
(If death occurred in a hospital or institution,
Ward
give its NAME instead of street and number)
2 FULL NAME
Alice A Gulick
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
(Usual place of abode)
158 Cliff Av
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
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Marr
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Russell A Gulick
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
Years 9 Months 22ays
If less than 1 day
Hours
Minutes
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
Housework
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
9/37
11 Total time (years) spent in this occupation
25
12 BIRTHPLACE (City)
(State or country)
New Brunswick N J
13 NAME OF
FATHER
William Pennington
14 BIRTHPLACE OF FATHER (City)
(State or country)
--
15 MAIDEN NAME
OF MOTHER
Alice Cronk
16 BIRTHPLACE OF MOTHER (City) (State or country)
17 Russell A Guliok husband
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
10/9/37 19.3
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Oct 6/37
193
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
9/23/37
10/6/37
19.3
,19 ......
. to.
I last saw h.
alive on
10/6/37
19
death is said
to have occurred on the date stated above, at12:50am. The principal cause of death and related causes of importance in order of onset were as follows: brain tumor (suspect) Dateefonset
circulatory collapse
12 hrs
Contributory causes of importance not related to principal cause:
cerebellar exploration
10/5/37
Name of operation
Date of
What test confirmed diagnosis?
Was there an autopsy? yes
20 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
W.B. Osgood
M. D.
(Address)
P Bent Brigham Hosp Date 10/6
193 .. 37
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Town Com New Brunswick N J
(Cemetery)
(City or town)
DATE OF BURIAL
19 3
10/9/37
22 NAME OF
UNDERTAKER
Ç R Bennison
Winthrop
ADDRESS
Received and filed
NUV 2 1 1937
19
(Registrar of City or Town where deceased resided)
important.
50m-9-'31. No. 3385-K
1 3 SEX F 7 AGE 42 OCCUPATION PARENTS Informant (Address) A TRUE COPY, tion should be carefully supplied. AGE should be stated LAACILf. PHYSICIANS should state CHUse year) . OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
No. ... Peter ... Bent .. Brigham.Hosp ..... .St.,
(If U. S.
War Veteran,
specify WAR)
tumor-type unknown
301
in plain terms, so that it may be properly classified. Date of onset and exact statement of OCCUPATION are very important. See instructions and extracts from the laws on back of certificate.
100m-12-'35. No. 6156E
17
Frank & Damon (atrodo)
Informant
(Address)
Sart at Dieser mais
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed, with me BEFORE the burial or transit permit was issued: William D. Childress
(Signature of Agent of Board of Health or other)
agent November 14/3)
(Oficial Designation) (Date of Issue of Permit)/
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
November
14
1937
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY. That I attended deceased from
October. 28
19 07 to November. 14, 1937
I last saw h ..... Y .. alive on
November. 14, 1937, death is said
to have occurred on the date stated above, at .. 8. P.M. The principal cause of death and related causes of Importance in order of onset were as follows:
Date of Oaset
Chronic Murcarditis
care.
...
Chronic
isphritis
Tears
Chronvie arthritis
years -
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)
Edward
,
M. D.
(Address) 200 uneitrato byl
Date
1 ... 19.3 .. ] ..
21 Malnut grove Danvers
Place of Burial, Cremation or Removal.
DATE OF BURIAL 1217
(City or Town) 193 7
22 NAME OF
William H Crosby
UNDERTAKER
ADDRESS
15 Obory et Dannero
Received and filed.
DEC. 7
19.3.7
A TRUE COPY ATTEST
(Registrar)
1
PLACE OF DEATH
Suffolk. Y (County) Minttrop (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No.
$700
§ (If death occurred in a hospital or institution, Ward \ give its NAME instead of street and number)
2 FULL NAME
Marion a Damon
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No ...
104 Highland ave
St.,
.Ward,
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
2
years
months
days.
How long in U.S., if of foreign birth?
years
months
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Jamale White
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
Or DIVORCED
(write the word)
Single
5a If married, widowed, er divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 61
AGE .. Years ... .. Months Days
If less than 1 day
.Hours ............ Minutes
OCCUPATION
& Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
at Home
9 Industry or business in which
work was done, as silk mill,
ww mill, bask, etc ..
10 Date deceased last worked at
11 Total time (years)
spent in this
occupation.
this occupation (month and
year)
Danvers
12 BIRTHPLACE (City)
(State or country)
Maso
18 NAME OF
FATHER
William J. Damon
14 BIRTHPLACE OF
FATHER (City)
..
No Reading
PARENTS
(State or country)
15 MAIDEN NAME
OF MOTHER
Caroline Hendergen
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Maine
Relation, if any
(City or town making return)
104 Highland ave No ...
St.,
(If U. S. War Veteran
specify WAR)
(Usual place of abode)
Statement of occupation. - Precise statement of occupation is. very important, so that the relative healthfulness of various pur- suits 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 bus- iness, report the occupation prior to retirement. Children not gainfully employed may be returned as AT SCHOOL OF 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 whatever 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 partic- ular kind of work done and return that, as SPINNER, WEAVER, etc.
In stating the industry or business, avoid the use of such gen- eral 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 ENGIN- EER, 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 nepbritis ....
1921
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.
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 sup- posed 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 satisfactory written statement con- taining 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 re- quired by law, or in lieu thereof a certificate as hereinafter pro- vided. If there is no attending physician, or if, for sufficient rea- sons, his certificate cannot be obtained early enough for the pur- pose, 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 attend- ing 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, from one town to an- other 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 a removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was re- moved 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 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 ap- pear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate. shall forthwith counter- sign it and transmit it to the clerk of the town for registration. The person to whom the permit is so given and the physician cer- tifying 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. (TER- CENTENARY EDITION.)
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 cemetery or burial ground in which the interment is made. . . .- CHAP. 114, SEC. 46, G. L. (TERCENTENARY EDITION.)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the ob- servance 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 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 septi- cemia), 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.
-
-
301
Sufflok
....
(County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
230
Registered No
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Inez Clayton (Bennett ) Dow
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
198 Cottage Park Road
Ward,
(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
4 COLOR OR RACE
white
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed, or divorced HUSBAND of Herbert marave wifeb&W (Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 50 Years 1 Months
8 Days
If less than 1 day Hours .Minutes
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
House work
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc ........
Own home
10 Date deceased last worked at
11 Total time (years)
this occupation (month and uly 1937
spent in this
occupation.
26
12 BIRTHPLACE (City).
Provincetown
(State or country)
Massachusetts
18 NAME OF
FATHER
Samuel Bennett
14 BIRTHPLACE OF
Provincetown
FATHER (City)
(State or country) Massachusetts
15 MAIDEN NAME
OF MOTHER
Irene Smith
Provincetown
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Massachusetts
17 Herbert C. Dow
Relation, if gny
(husband
)
(Address) 198 Cottage PK. Rd Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE The burial or Transit permit was issued: N.m. S. Childress (Signature of Agent of Board & Health or other)
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