Town of Winthrop : Record of Deaths 1939, Part 80

Author: Winthrop (Mass.)
Publication date: 1939
Publisher:
Number of Pages: 560


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1939 > Part 80


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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301A


1


PLACE OF DEATH


Suffolk (County)


Winthrop (City or Town) No.94 Lincoln


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.


200


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


2 FULL NAME


Herbert Stanley Macgowan


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


(a) Residence. No.94 Lincoln


(Usual place of abode)


St.,


.Ward,


(If nonresident, give city or town and state)


Length of residence in city or town where death occurred


5 years 6


months


days.


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


years


months


dayı.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


Male


4 COLOR OR RACE


white


5 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


Married


6a If married, widowed, or divorced


Mary ..


Adelaide Wider


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


28


Years


4


Months


17


Days


If less than 1 dey


Hours


.Minutes


OCCUPATION


9 Industry or business In which


work was done, as silk mill,


saw mill, bank, etc ..


10 Date deceased last worked at


11 Total time (years)


spent in this


occupation ...


this occupation (month end


year)


.Se.p.t .....


1.9.39


7


12 BIRTHPLACE (City).


NewYork


(State or country)


New York


13 NAME OF


FATHER


Robert Macgowan


PARENTS


14 BIRTHPLACE OF


FATHER (City)


Unknown


(State or country)


Unknown


15 MAIDEN NAME


OF MOTHER


Helen Stanley


16 BIRTHPLACE OF


MOTHER (City)


New York


(State or country)


New York


Relation, if any


17


Informant Mary ("Tiver) Macgowan( Wife


(Address)


I HEREBY CERTIFY, that a satisfactory standerd certificate of death was filed with me BEFORE the budal or fragsit permit was issued: Www. D. Childress y Signature of Agent of Board of Health or other ) Health Officer (Official Designation) (Date of Issue of Pormit) 10/2/39


18 DATE OF


DEATH


Sept


30


(Month)


(Day)


(Year)


19 I HEREBY


CERTIFY, That I attended deceased from


1


19.


to


19


I lest saw b .......... alive on


19


death is said


to have occurred on the date stated above, at 8: 30P


m


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


Date of Onset IMPORTANT


Natural Come : Probate


Contributory causes of Importance not related to principal cause: .


Chance Sudraditi


1128.


Rheumatin


Name of operation.


none.


What test confirmed diagnosis ?.


Date of.


Was there an autopsy ?.


N:


20 Was disease or Injury in any wey releted to occupation of deceased?


If so, specify 36


Parker


(Signed)


M. D.


(Address Writing Braw


Daten.


Lect 2 1939


21 ..


Winthrop


Winthrop


Place of Burial, Cremation or Removal.


(City or Town)


DATE OF BURIAL


October


2


1939


......


.. 19


22 NAME OF


Richard to White


FUNERAL DIRECTOR


ADDRESS


147 Winthrop ST Winthrop


Received and filed. 19


(Registrar)


100m.9.'37. No. 1859-i.


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.


St.,


(If U. S.


War Veteran


specify WAR)


1939


AGE


8 Trede, profession, or particular


kind of work done, es spinner,


sawyer, bookkeeper, etc.


Salesman


(x+ 30 1/39


No


IN !!! VI MADDALMUSEITS


GOVERNING THE


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 SPINNEa, 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- ZEA, 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:


Date of Omset


Arteriosclerosis ....


1915


Chronic interstitial nepbritis


1921


......


Carebral 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 he 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.


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, bis 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 bc, 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 he 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 deathis 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.


RM 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


important.


50m-11.'36. No. 9080-g


17


Relation, if any


Informant


(Address)


DSHI


A TRUE COPY.


ATTEST:


(Registrar of city or town where death occurred) 9/18/39


DATE FILED .19


MEDICAL CERTIFICATE OF DEATH


18 DATE OF


Sep. 10, 1939.


(Month) (Day)


(Year)


19 I HEREBY CERTIFY, That I attended deceased from


August


14,


.,19 ...


... , to ..


,39


Dep.


10,


19


| last saw h.LI:1 ... alive on


Sep. 10,


19


death Is said


to have occurred on the date stated


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


General


arteriosclerosis


1920


Date ofonset


Chr.myocarditis 1934


Contributory causes of importance not related to principal cause:


Name of operation


Date of.


What test confirmed diagnosis? .......


Was there an autopsy?no ...


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


If so, specify.


(Signed)


Wyer .... Asekoff.


(Address)


M. D.


Date/1.5


1939 ...


21


Linthron


Winthro


Place of Burial. Cremation or Removal.


(City or Town)


DATE OF BURIAL9 /13/39


19


22 NAME OF


Richard White


UNDERTAKER


ADDRESS


Winthrop


Received and filed 19 ....


(Registrar of City or Town where deceased resided)


1


PLACE OF DEATH


County) Danvers


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


Danvers


(City or town making return) 201


Registered No.


(If death occurred in a hospital or institution,


give its NAME instead of street and number)


George Asa Everbeck


2 FULL NAME


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


417 Lincoln


St.,


Ward,


winthro"


(If nonresident, give city or town and state)


mos.


days.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


male


4 COLOR OR RACE


white


5 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


DEATH


married


5a If married, widowed ,


HUSBAND of


LILIaneManwaring


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


6 IF STILLBORN, enter that fact here.


74


7


AGE


Years


Months


Days


If less than 1 day Hours .. Minutes


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


OCCUPATION


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


10 Date deceased last worked at


11 Total time (years)


spent in this


occupation


this occupation (month and


year)


(E)roston


12 BIRTHPLACE (City)


(State or country)


13 NAME OF George O. Everbeck FATHER


PARENTS


14 BIRTHPLACE OF


FATHER (City)


Boston


(State or country)


15 MAIDEN NAMEALIzada M. Dill OF MOTHER


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


Maine


(City or Town) Julivers State Hospital No.


St.,


...... ..... .Ward


(If U. S.


War Veteran,


specify WAR)


(a)


Residence. No.


(Usual place of abode)


Length of residence in city or town where death occurred


yrs.


mos.


27.


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


yrs.


Dove 557 m.


Essex


RM 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


important.


50m-11-36. No. 9080-g


PLACE OF DEATH


(County)


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


ROSTON


(City or town making return)


8086


202


Registered No. (If death occurred in a hospital or institution,


give its NAME instead of street and number)


William J Rivers


2 FULL NAME


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


Terrace Ave


.St., .........


Ward,


(If nonresident, give city or town and state)


mos.


days.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


5 SINGLE


(write the word)


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 42


7


AGE


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 ...


Laborer


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)


5/39


11 Total time Gears)


spent in this


occupation


12 BIRTHPLACE (City)


(State or country)


Halden


13 NAME OF


Limery Rivers


14 BIRTHPLACE OF


FATHER (City)


(State or country)


Holyoke


15 MAIDEN NAME


OF MOTHER


Anastasia B O'Neil


16 BIRTHPLACE OF


MOTHER (City)


(State or country)


Newfoundland


17 Relation, if any Mother


Informant


(Address)


A TRUE COPY.


ATTEST :.


James Q. Bank.


(Registrar of city or town where death occurred)


DATE FILED 19


18 DATE OF


DEATH


Sopt 19/30


(Month)


(Day)


(Year)


19 I HEREBY CERTIFY, That I attended deceased from 8/26/39


19


to ... 9/19/39


19


I last sawsh.


alive 00/19/39


19


death Is said


to have occurred on the date stated above,Zab.


m.


The principal cause of death and related causes of importance in order of


onset were as follows:


Dateofonset


carcinoma of pancreas-head-


with metastases


12/$8


Contributory causes of importance not related to principal cause:


Name of operation


Date of.


What test confirmed diagnosis?


Was there an autopsy&.S.


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


If so, specify.


(Signed)


3 Osgood


(Address)


Pat


er B & Hosp


Date


00/10/30


.19


21


Place of Burial, enmattonpor Kimdirop


(City or Town)


DATE OF BURIAL


9/21/30


19


22 NAME OF


UNDERTAKER


C R Bennison


ADDRESS


Winthrop


Received and filed


9/21/39


19


(Registrar of City or Town where deceased resided)


1


(City or Town) Poter Bent Brigham Hosp No.


St.,.


....... ....... .Ward


(If U. S. War Veteran,


specify WAR)


winthrop


(a) Residence. No ...


(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.


PARENTS


M. D.


OCT211139 **


ஸீ சத்து


R


INDING


1 R-302


OCCUPATION tion 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 is very PARENTS


important.


50m-11-'36. No. 9080-g


A TRUE COPY.


ATTEST:


DATE FILED


(Registrar of city or town where death occurredK Oct. 13, 1939


MEDICAL CERTIFICATE OF DEATH


3 SEX


male


4 COLOR OR RACE


white


5 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


married


5a If married, widowed, or divorced


HUSBAND of


Lillian Pearson


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


6 IF STILLBORN, enter that fact here.


AGE


Months


? Days


If less than 1 day .Hours .. Minutes


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


9 Industry or business In which


work was done, as silk mill,


saw mill, bank, etc.


Lass.BondingIns.Co


10 Date deceased last worked at


11 Total time (years)


this occupation (month and.


1936


year)


spent in this


occupation ....


30


12 BIRTHPLACE (City)


New Britian


(State or country)


Conn


13 NAME OF


FATHER


Leonard Moore


14 BIRTHPLACE OF


FATHER (City)


Litchfield


Conn.


(State or country)


15 MAIDEN NAME


OF MOTHER


( cannot be learned )


16 BIRTHPLACE OF


MOTHER (City)


(State or country)


( cannot be learned )


17 osnital Records


Relation, if any (


)


22 NAME OF


Richard White


UNDERTAKER


ADDRESS


inthron, lass.


Received and filed


Oct. 13, 1939


19


(Registrar of City or Town where deceased resided)


1


PLACE OF DEATH


Suffolk (County)


Chelsea


(City or Town)


No. Soldiers'


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


Chelsea


(City or town making return)


Registered No.


203


(If death occurred in a hospital or institution,


nome Hospital St., ............ .Ward give its NAME instead of street and number)


2 FULL NAME


Charles


i. oore


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


(If U. S.


War Veteran.


specify WAR) ...... pani.sh


-


(a)


Residence. No.


(Usual place of abode)


Length of residence in city or town where death occurred


yrs.


70 Summit Ave.


St.,.


Ward,


Winthrop, Lass.


(If nonresident, give city or town and state)


mos.


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


mos.


days.


PERSONAL AND STATISTICAL PARTICULARS


18 DATE OF


DEATH


Oct. 13, 1930


(Month)


(Day)


(Year)


19 I HEREBY CERTIFY, That I attended deceased from


Oct. 11,


19.39.


to.


Uct. 13,, 19 39


last saw im alive on Oct.


13


1939, death Is said


to have occurred on the date stated above, at ....... Q.


m.


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


Arteriosclerotic heart dis ase Cardiac decompensation 10/4/39


Contributory causes of importance not related to principal cause:


? Uld cerebral accident


?


a ... 193.


Name of operation ..... no.n.e


What test confirmed diagnosis?


Date of


clinical


Was there an autopsy ?. n.Q.


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


If so, specify.


(Signed) John F. Conlin


M. D.


(Address)Soldiers!


some


Date 1.0/139 39


"Chelsea


2New Britian, Conn.


Place of Burial, Cremation or Removal.


(City or Town)


DATE OF BURIAL


Oct. 16, 1939


19


Informant (Address)


7 73 Years


NIDHYIN


ONIONIO HOA


5


-


C.


ʼ


NOV -91000 MM


M R-303 B


Supick (County)


The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH


To be filed for burial permit with Board of Health or its Aget Registered No.


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


2 FULL NAME


Martha Ette Vinneau


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


(Usual place of abode)


Length of residence in city or lown 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


MARRIED


WIDOWED


or DIVORCED


(write the word)


married


5a If married, widowed, or divorced HUSBAND of Starting (or) WIFE of (Husband's name in full)


6 IF STILLBORN, enter that faet here.


AGE


73


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.


Housewife


Own Home


10 Date deceased yast worked at


this occupation month and 934


year)


11 Total time (years) spent in this occupation


45


12 BIRTHPLACE (City) ...


(State or country)


Vermont


Unknown) Cushing


Canada


Matilda Connelly


Cannot be learned.


17 Stander I. Vienneau


Informant (Address) 8 Viste are Withno


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Im. Culdrene J (Signature of Agent of Board of Hean or other)


Health fficer Official Designation Y


10/1/39 (Date of Issue of Permit)


MEDICAL CERTIFICATE OF DEATH


18 DATE OF


DEATH


Oct - 8-1939


(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.) Septic Threat Semilite


Recent Fracture Right Jenner


Said to have fallen accidentally to Koor in hand it newton mass about July- 21-1939


(See reverse side for description for unknown person )


20 IN WHAT CITY OR TOWN


WAS INJURY SUSTAINED ?..


(Signed)


That Suckley


(Address)


Bestã


.1936


21 PLACE OF BURIAL,


CREMATION OR REMOVAL


Calvary Concord H.A.


(Cemetery)


(City or town)


DATE OF BURIAL


October 10


198


22 NAME OF


UNDERTAKER


John F. OMalay


ADDRESS Wentto pass.


Received and filed


1939


(Registrar)


(If U. S.


War Veteran,


specify WAR)


(a) Residence.


No ...


f Vine are Winthrop.


.St.,


........... Ward,


(If nonresident, give city or town and state)


1 3 SEX Female 7 13 NAME OF FATHER 14 BIRTHPLACE OF FATHER (City) 15 MAIDEN NAME OF MOTHER 16 BIRTHPLACE OF PARENTS OCCUPATION MOTHER (City) (State or country) information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, so that it may be properly classified under the International Classification of Causes of Death. See reverse side for extracts from the laws relative to the return of certificates of death. 5m-12-'34. No. 2938-g N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of (State or country)


PLACE OF DEATH


(City or Town) Minthub Community Hospital No.


Ward


M. D.


(Gige maiden name of the in full)


EXTRACTS


FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH




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