USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1938 > Part 57
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yrs.
mos.
days. How long in U. S., if of foreign birth?
JTs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
(write the word)
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Single
5a If married, widowed, or 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 AGE 42 .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.
Bar ...... tender
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)
New Bedford
Mass .
13 NAME OF FATHER Alfred Sylvia
PARENTSF
14 BIRTHPLACE OF FATHER (City) (State or country)
Azores
15 MAIDEN NAME
OF MOTHER
Mary Simmons
16 BIRTHPLACE OF MOTHER (City) (State or country) Azores
17 InformaAlfred ..... Sylvia
(Address) Orchard St. How Bed ford
A TRUE COPY.
Aug 2 1938
.ATTEST:
(Registrar of city or town where death occurred)
DATE FILED Frederick, 1 13
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
July ... 31.1938
(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)
Fracture of skull
......
Struck by an automobile
Accident
20 If death was due to external causes (VIOLENCE) fill in the following :
Accident,
Suicide or
Date of injury.
Homicide ?
Accident
7/31
19
38
Where did
injury occur ?
Watertown
Mase.
Manner of
Injury.
Nature of
Injury
21 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
M. D.
(Address)
David .C .DOw.
Date
19
1587 Mass . AVE
7/31
38
22 PLACE OF BURIAL,
CREMATION OR REMOVAL
St Contas
New Bedford
DATE OF BURIAL
19
23 NAME OF
Aug 2 1938
UNDERTAKER
Chas. a Frates
ADDRESS
265 County St.
Received and filed.
19
(Registrar of City or Town where deceased resided)
25m-2-'30. No. 7997-e
1
PLACE OF DEATH
No .. Cambridge ... Hospital St.,
..... Ward
(If U. S.
War Veteran,
specify WAR)
-
(City or town and State)
RECEIVE
TOM
11 17
-
5
7 6
HRO
AUG-81938 **
F301
ATIEE AC NEA TU
JEVACTI V. DUVCICIANC .L .-. 1J -4.UN are very
in plain terms, so that it may be properly classihed, Date of onset and exact statement of UL
PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
Revere nouque 0/10/58 The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
Winthrop Community Hospital No. Baby Boy Thurston (Premature)
(If death occurred in a hospital or institution,
St.,
.Ward \ give its NAME instead of street and number)
(If U. S.
War Veteran
specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
N8.
154 Cresant Ave Revere
St.
.Ward,
(If nonresident, give city or town and state)
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How long in U.S., if of foreign birth?
years
months
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
taly
3/
1938
38
A last saw h ..... i.allve on.
·
......
1.55PM
to have occurred on the date stated above, at ...
Dale of Onset
The principal cause of death and related causes of Importance la order of onset
were as follows:)
Prematurity
Tum
Contributory causes of importance not related to principal cause:
Name of operetion ..
June
What test confirmed diagnosis ?.
Was there an eutopsy ?.
20 Was disease of Injury in any wey related to occupation of deceased?
If so, specify.
(Signed)
(Address) Cescuhas Date 8/1
........ , M. D.
1938
Woodlawn
Everett
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL. August 3 1938
............. .... . ... . 19
22 NAME OF Bicha UNDERTAKER
ADDRESS
......
147 Winthrop St Withrop Mass
SI HEREBY CERTIFY that a satisfactory standard certificate of death was Med with me BEFORE the burial. or transit permit was issued: Wm. D. Clusarea
(Signature of Agent of Board of Health or other)/
/Health Affiche
8/2/38
.....
Received and flied ...
AUG - 1938
19
(Oficial Designation) (Date of Issue of Permit)
····· 19. 19 / I HEREBY CERTIFY.) That f attended deceased from tiology 31 19.2 .... 19. 31 ....... 19 death Is sald July 31 3)
(Month)
(Day)
(Year)
6a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter thet fact here.
7 AGE .. Years. Months.
.. Days
if less than 1day .Hours. Minutes
8 Trede, profession, or perticular kind of work done, es spinner. sawyer, bookkeeper, etc ......
9 Industry or business in which work was done, as ailk mill, saw mill, bank, etc .......
10 Date deceased last worked at
11 Total time (years)
spent in this
occupation ....
this occupation (month and
yeer)
12 BIRTHPLACE (City)
Winthrop
(State or country) Massachusetts
13 NAME OF
FATHER
Franklin D Thurston
14 BIRTHPLACE OF
Medford
FATHER (City)
(State or country) Ja ss
Tatten
Malden
(State or country)
Mass
17 Franklin Thursten
Informant (Address) 154 Cresent Ave Revere Mass
21 ..
Father any
1
8 SEX Male (or) WIFE of OCCUPATION 1 16 BIRTHPLACE OF PARENTS MOTHER (City) important. See instructions and extracts from the laws on back of certificate. N. D-WNIE FLATNET, WITTT WANT AUNTS DEVE BOTTEN BUT TOS DE 15 MAIDEN NAME OF MOTHER 100m-12-'35. No. 6156E
4 COLOR OR RACE
White
5 SINGLE
(write the word)
Single
MARRIED
WIDOWED
Or DIVORCED
2 FULL NAME
Registered No.
140
(Registrar)
A TRUE COPY ATTEST :
Date of.
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 ovcr. If the occupation had been given up or changed on account of the disease causing death, report the occupation prior to illness. If the deccased had retired from bus- iness, 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, ctc. 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 off
with, alter 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 hoard, 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 hody is buried. No such permit shall be issued until there shall nave been delivered to such board, agent or clerk, as the case may bc. a satisfactory written statement con- taining the facts required hy law to he 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- anired 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 he obtained early enough for the pur- pose, or is insufficient, a physician who is a member of the hoard 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 hody 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 huried 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 hy traumatism (including resulting septi- cemia), and by the action of chemical (drugs or poisons), thermal. or electrical agents, and deaths following ahortion, 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.
AV R-302
PARENTS tion should be carefully supplied. AGE should be stated LAACILI OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very OCCUPATION
important.
A TRUE COPY.
James Q. Burke
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED 6/28/38 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
June 25/38
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
6/25/38
,19
.. , to.
3/25/38
.. , 19
I last saw h ... g.
im
6/25/38
.. alive on.
19
death is said
to have occurred on the date stated above at .. m.
10:10p The principal cause of death and related causes of importance in order of onset were as follows: Dateefonset prematurity 6-mos
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)
C-A-Powell
M. D.
(Address)
Mags Memorial Hosp
. Date.
0/209 33
21 PLACE OF BURIAL,
CREMATION OR REMOVALnthrop
Linthrop
DATE OF BURIAL
0/28/33
19
22 NAME OF
UNDERTAKER
C RBennison
ADDRESS
Winthrop
Received and filed 19
AUG 17 1938
(Registrar of City or Town where deceased resided)
50m-9-'31. No. 3385-g
PLACE OF DEATH
SURPOLE BOUWYON
(City or Town) Mass Memorial Hosp
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town making return),
141
Registered No .... 5402
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
-
Costonis
(If deceased is a married, widowed or divorced woman, give also maiden name.)
173 Shirley
.St.,.
..........
Ward,
Winthrop
(If nonresident, give city or town and state)
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Sing
5a If married, widowed, or 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 AGE
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 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)
Boston
(State or country)
13 NAME OF
FATHER
Arthur Costonis
14 BIRTHPLACE OF
FATHER (City)
Albania
(State or country)
15 MAIDEN NAME
OF MOTHER
Sylvia Bonaccarco
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Chicago Ill
17 mother
Infor mant
(Address)
A MENT PATSICIANS snou
1
No
St.,
....... Ward
(If U. S. War Veteran, specify WAR)
(a)
Residence.
No.
(Usual place of abode)
Length of residence in city or town wbere death occurred
yrs.
mos.
days.
How long in U. S., if of foreign birth?
yrs.
(Cemetery)
(City or town)
MR-302
CRIAREventuem of informa-
THIS IS A PERMANENT
tion should be carefully supplied. ALL should be stateu CAMCILI, MIAMI OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very OCCUPATION
important.
A TRUE COPY.
ATTEST:
James Q. Burine
fRegistrar of city or town where death occurred)
- 19 ..
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
Jun 27/38
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
6/26/38
19
to
6/27/38
., 19
I last saw hor
.alive on
6/27/38
,19.
death is said
to have occurred on the date stated above, Ott .m.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
arbasclerosis-hypertension
·cerebralhemorrha go.
10hrs
.yre ...
Contributory causes of importance not related to principal cause:
laceration .. of ... forchead
6 26/38
Name of operation suturo of lecoration Dats /26/38 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)
RIT Wallace
M. D.
(Address)
269 Bencon St
Date
6/27/38
21 PLACE OF BURIAL
CREMATION OR REMOVWinthrop Winthrop
(Cemetery)
6/29/38
19
DATE OF BURIAL
22 NAME OF
UNDERTAKER
P .... C .... Kirby
ADDRESS
Boston
Received and filed
6/30/38
AUG . .
(Registrar of City or Town where deceased resided)
50m-9-'31. No. 3385-x
PLACE OF DEATH
SUFFOLK
1 (County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
DOSTON
(City or town making return)
Registered No.
5467
(If death occurred in a hospital or institution,
5
Ward
give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No ...
6.Washington Ave
St.,
Ward,
Winthrop
(Usual place of abode)
Length of residence in city or town wbere 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
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
5a If married, widowed, or divorced IIUSBAND of
(or) WIFE of
Patri Give maiden name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7.66 AGE
Years Months Days
If less than 1 day
.Hours
Minutes
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).
6/38
11 Total time (years) spent in this occupation.
0
12 BIRTHPLACE (City)
(State or country)
Boston
PARENTS
(State or country)
15 MAIDEN NAME
OF MOTHER
Margaret Ilyde
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Informant (Address)
husband
1
(City or Town)
No
Mass Gen Hosp
St.,.
Catherine Lane
(If U. S.
War Veteran,
specify WAR)
142
(If nonresident, give city or town and state)
(City or town)
19
DATE FILED
13 NAME OF
FATHER
William Pomfret
14 BIRTHPLACE OF
FATHER (City)
Ireland
MR-302
tion should be carefully supplied. AUL snoulu De OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very PARENTS
important.
A TRUE COPY.
James Q. Burke
ATTEST:
....
(Registrar of city or town where death occurred)
DATE FILED
6/30/38
.. 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
June 27/38
(Month)
(Day)
(Year)
5a If married, widowed, or 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.
55
7
AGE
Years
3
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 ...
steward
9 Industry or business In which
work was done, as silk mill,
saw mill, bank, etc.
SS
10 Date deceased last worked at
this occupation (month and
year)
/35 11 Total time (yea1) spent in this occupation
12 BIRTHPLACE (City)
(State or country)
England
13 NAME OF
FATHER
Thomas Young
14 BIRTHPLACE OF
FATHER (City)
Ehg land
(State or country}
0
15 MAIDEN NAME
OF MOTHER
---
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
17
Informant
(Address)
50m-9-31. No. 3385-K
PLACE OF DEATH
SUFOLK
(County) DOSTON 1
(City or Town) Nass General Hosp
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town making return). 5471 143
Registered No.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Samuel H Young
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence.
No.
(Usual place of abode)
33 Court 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
M
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Marr
Jennie 5 Peterson
19 IHEREBY CERTIFY, That I attended deceased from
6/27/38
19
6/27/38
19
I last saw hi.ya ...... alive on ...
6/27/38
19
death is said
to have occurred on the date stated above,latp.
m.
Datesfonset vrs The principal cause of death and related causes of importance in order of onset were as follows: cirrhosis.of.the liver esophageal varices, with
rupture
1"da"
Contributory causes of importance not related to principal cause:
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)
M .J .... Rheos
M. D.
(Address)
Mass Gen Hosp
Date .6. 28 .19.38.
21 PLACE OF BURIAL,
CREMATION OR REMOVALOodlawn.
Everett
(Cemetery)
6/29/38
(City or town)
DATE OF BURIAL
19
22 NAME OF
UNDERTAKER
CJ Berglund
ADDRESS
Arlington
Received and filed
AUG 1 7 1938
19
(Registrar of City or Town where deceased resided)
IS A PERMANENT RECORD. Every item of informa- aluu
1
No.
St., ...........
Ward
(If U. S.
War Veteran,
specify WAR)
to
الدرجـ
F301A
PLACE OF DEATH
Sauffrolle notifica (County) Keithap/9/38 (City or Town)
No. 264 River Road
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 or its Agent.
Registered No.
144
§ (If death occurred in a hospital or institution, Ward \ give its NAME instead of street and number)
2 FULL NAME
Bassie Bergen
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No. 33 Grove 87
(Usual place of abode)
Leogth of residence in city or town where death occurred
years
months
days.
How long in U.S., if of foreign birth?
years
months dayı.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Temple
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
widowed
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
If less than 1 day
Years.
Months
Days
Hours ..... .Minutes
8 Trade, profession, or particular kind of work done, as spinnei. sawyer, bookkeeper, etc .....
at home
9 Industry or business in which work was done, as ailk mill, saw mill, bank, etc.
10 Date deceased last worked at
11 Total time (years)
this occupation (month and
spent in this
occupation.
12 BIRTHPLACE (City) (State or country)
Russia
13 NAME OF
FATHER
Jacob Seltzer
14 BIRTHPLACE OF
FATHER (City)
(State or country) Russia
15 MAIDEN NAME
OF MOTHER
Gastrucha Kirschick
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