USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1940 > Part 21
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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 usual occupation prior to illness. If the deceased had retired from husl- ness, report the usual oeenpatlon prior to retirement. Children not galnfully employed may he returned as at school or at home. For a woman whosc only occupation was that of home housework, write housework. For a person engaged In domestic service for wages, however, designate the occupation hy the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
R-302
PLACE OF DEATH
(County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No
2215
(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
(If U. S. War Veteran, specify WAR)
(a) Residence. No ......
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
....
years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX 1 Fem
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
(write the word)
18 DATE OF
DEATH.
march
7
(Month)
(Day)
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive.
years 7 IF STILLBORN, enter that fact here.
AGE 81 Years .. Months. Days
If less than 1 day Hours Minutes
Usual 9 Occupation:
Industry
10 or Business:
at home
II Social Security No.
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Jacob helson
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Sarah
-
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
Relation, if any
Informant.
(Address)
17 Jacob score )
A TRUE COPY.
ATTEST:
Jaques Q. Brunhe
(Registrar of city or town where death occurred)
DATE FILED
3/9/40
19
Other conditions
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of.
Of autopsy
What test confirmed diagnosis ?
20 Was disease or Injury in any way related to eccupation of deceased ?
If so, specify
B.a. Udelson
(Signed)
(Address)
3/7/199
M. D. 40
21 PLACE OF BURIAL.
CREMATION OR REMOVAL
Chelsea Woburn
DATE OF BURIAL
3/4/40
40
(Cemetery) (City or Town) 19
......
22 NAME OF
FUNERAL DIRECTOR
m. Staneteky
ADDRESS
Received and filed
19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 8427-f
Suffolk
1
(City or Town)
Hebrew aged Home
No.
Rebecca
Livre
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
361 Shirley St
St.
Winthrop
(If nonresident, give city or town and state)
1940 ( Year)
19 | HEREBY CERTIFY ..
That I attended deceased from
3/7/40
3/1/60
19
.,
to ....... 19
I last saw h .......... alive on
3 /7/ 194 P death is said
to have occurred on the date stated above, at ............
Immediate cause of death.
Pneumonia
Duration
....... 3/4/40
Due to
myocarditis
Due to
arterio seturi
PHYSICIAN
Underline the cause to which death should be charged sta- tistically.
PARENTS
more
www sue Wtswsta Itstucq Ty another City of town at the time 6. Sec. 12, G. L.)
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible after the close of the month in which the death occurred. (See Chap. 46,
(
2
7
IN THR
APR121040 MM
R-302
PLACE OF DEATH
ESSanty)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
(City or town making return) 63
Registered No.
(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
(HELA E a married traged or divorced woman, give also maiden name.)
(a) Residence. No ...
(Usual place of abode)
Length of stay: In hospital or institution ....
(Specify whether)
56 Sagemore
AVE.
years
months
days. 18
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
18 DATE OF
DEATH
Mar. 8, 1940.
(Month)
(Day)
(Year)
IS I HEREBY CERTIFY
red.
That I attended deceased from
.? , 19
to.
19
.....
I last saw
alive on
to have occurred on the date stated above, at.
.m.
Duration
Immediate cause of death
generali zou
Chr.Lvocusto.
3726
8
AGE
85
Months.
Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation:
Painter(retired)
Industry 10 or Business:
II Social Security No ..
12 BIRTHPLACE (City)
Cannot be learned
(State or country)
LOSGOR
13 NAME OF
FATHER
valter S. Dunn
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Halifax
(State or country)
N. 8.
15 MAIDEN NAME
OF MOTHER
Jane FlIna
16 BIRTHPLACE OF
MOTHER (City)
Dublin
(State or country)
'Ireland
(Address)
Date
5/32/40
21 PLACE OF BURIAL,
CREMATION , OR REMOVAL. .. \,
(Cemeteryn
(City or Town)
DATE OF BURIAL
3.199 /40
19.
22 NAME OF
FUNERAL DIRECTOR John 12
D'in Ley
ADDRESS
winthrop
19
(Registrar of City or Town where deceased resided)
waves city of sonra lu case the deceased resided in another city of town at the time
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
50m-10-'39. No. 8427-f
17
Informant.
(Address)
Relation, if any
A TRUE COPY.
ATTEST:
(Registrar of city or town Where ceath occurred)
DATE FILED 3/25/40
Other conditions
(Include pregnancy within 3 months of deathi)
PHYSICIAN
Major findings :
Of operations
Of autopsy
Date of.
Underline the cause to which death should be charged sta- tistically.
What test confirmed diagnosis ?
clinical
20 Was disease or Injury In any way related to occupation of deceased ? If so, specify.
(Signed)
Myer Asekoff
M. D.
Due to
Due to
Mar.
40
death is said
(Husband's name in full)
6 Age of husband or wife if alive. 7 IF STILLBORN, enter that fact here.
.years
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(If U. S. War Veteran, specify WAR)
St.
ii (If Woodresident,' give city or town and state)
Received and filed.
.19
1
No. Danvers State Hospital
TOWA
1
3
5
HP
APR121940 AM
..
- .
R-302
PLACE OF DEATH
Essex (County)
Danvers
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Dunvers
(City or town making return)
Registered No.
1 (If death occurred in a hospital or institution, St.
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
235 ... Court Road
. .St.
years
months
days
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE 5 SINGLE
MARRIED
white
WIDOWED
or DIVORCED
widowed
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
GeorgeHart
(Husband's name in full)
6 Age of husband or wife if alive.
7 IF STILLBORN, enter that fact here.
8
76
AGE
Years
Months.
Days
......
If less than 1 day
Hours
Minutes
Usual
9 Occupation:
Cannot be learned
Industry 10 or Business:
Il Social Security NALHut be learned
12 BIRTHPLACE (City)
Boothbay, Mains
(State or country)
13 NAME OF
FATHER
edwin Anderson
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Kaine
15 MAIDEN NAME
OF MOTHER
Vesta Webber
16 BIRTHPLACE OF MOTHER (City) (State or country)
Maine
17 Informant (Address)
A TRUE COPY.
ATTEST:
(Registrar, of city or town where death occurred) 3/12/40
DATE FILED
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
March 11, 1940.
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY. That I attended deceased from .
I last saw b
.. alive on.
40
death is said
to have occurred on the date stated above, at.
1.852
m.
Immediate, cause, of death ........ "
Duration 2 VYS Generalized arteriosclerosis 3yrs Bronchopneumonia
Due to
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Of autopsy
What test confirmed diagnosis ?.
20 Was disease or Injury In any way related to occupation of deceased ? no
If so, specify.
(Signed)
Malvin Goodman
. M. D.
(Address)
Date.
3/119 40
21 PLACE OF BURIAL,
BEMATION OR REMOVAL
(City or Town)
DATE OF BURIAL
3/13/10
19
22 NAME OF
FUNERAL DIRECTOR
Charius R. Bennison
ADDRESS
Winthrop
Received and filed.
afar 12 -H.J
19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 8427-f
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
1
No .. DanversState ... Hospital
.....
.........
give its NAME instead of street and number)
(If U. S.
War Veteran,
specify WAR)
"(H honest
Ifheit Live city or town and state)
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
(write the word)
years
PARENTS
K. Mochillipc
Relation, if any
Date of.
Underline the cause to which death should be charged sta- tistically.
....
19
..........
19.
.40
1
We svira tu tost tuc ucctastu festued in another city of town at the time
6 5
YROPN
ASS
APR121940 %1
1 R-305
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided as soon as possible Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
25m-10-'39. No. 8427-g
PARENTS
14 BIRTHPLACE OF FATHER (City)/
(State or country) Russia
15 MAIDEN NAME OF MOTHER Sarah (cannot be learned)
16 BIRTHPLACE OF MOTHER (City) Russia
(State or country)
17 Anin-law
Relation, if any
Informant.
(Address)
alme
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
Mar 18.
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH. March 14, 1940 (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.)
Broncho pneumonia
fractured leg. under
investigation
20 Accident, suicide, or homicide (specify)
Date of occurrence .. Where did Injury occur?
(City or town and State)
Did injury occur in or about the home, on farm, in industrial place, or in public place ?
Manner of
Injury
Nature of Injury
While at work ?
.Was there an autopsy ?
21 Was disease or lajury to any way related to occupation of deceased ?.
If so, specify
(Signed) 6. 2. O.Leary
(Address).
est Med Exam Date 3-14 1940
.. M. D.
22 ayudatti aduno- Statura Place of Burial, Cremation or Removal. City or Town)
DATE OF BURIAL
19
23 NAME OF
I. b. Stantteky
FUNERAL DIRECTOR
ADDRESS
Bootnumber
Received and filed
19
(Registrar of City of Town where deceased resided)
1
(If deceased is a married, widowed or divorced woman give also maiden name.)
36 Handside are
St.
Winthrop. mars
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution ..
(Specify whether)
years
months
days.
(If nonresident, give city or town and state)
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED wordower
(write the word) .
male white
widowed, or divorced Sarah Rembaum
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ...
(Husband's name in full)
6 Age of husband or wife if alive.
Years
7 IF STILLBORN, enter that fact here.
AGE
8 80 Years Months Days
li less than 1 day
Hours
Minutes
Usual 9 Occupation:
notion Peddler
Industry
10 or Business:
11 Social Security No. nonel
12 BIRTHPLACE (City)
(State or country)
turcia
13 NAME OF
FATHER
Joseph Chenofsky
PLACE OF DEATH
(County) Boston
(City or Town) 126 Kelsyth Road
No
utfolk
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(City or town making return)
Registered No.
2457
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
(If U. S. War Veteran, specify WAR).
61
2 FULL NAME
Serael Gehenafter
51. 1
- .
19
(Specify type of place)
march19,
..........
10
'0
11
1
APR121940 MM
R-302
1
PLACE OF DEATH
ST (County) [ K BOSTON Peter Bent Brigham Hapi No ...
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BUSIUN (City or town making return) 2744
Registered No
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(11 U. S. War Veteran, specify WAR) Winthrop mass
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
years
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX Fem
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
(write the word)
18 DATE OF
DEATH.
March 22 1940
(Month)
(Year)
(Day)
That I attended/ deceased from
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive. Yecrs
7 IF STILLBORN, enter that fact here.
ÅGE ..
Months
.Days
If less than 1 day
Hours.
Minutes
Usual
9 Occupation:
at home
Industry 10 or Business:
11 Social Security No ...
12 BIRTHPLACE (City)
(State or country)
EBoston
13 NAME OF
FATHER
James a Burns
14 BIRTHPLACE OF
FATHER (CHY)
(State or country)
Boston mass
15 MAIDEN NAME
OF MOTHER
anna Glynn
16 BIRTHPLACE OF MOTHER (City) Boston (State or country)
17
Informant
(Address)
Relation, if any
A TRUE COPY
ATTEST:
James Q.Burke
(Registrar of gity or town where death occurred)
DATE FILED 3/2.6/40
19
Major findings :
Of operations
Of autopsy
Cympline ext lung
What test confirmed diagnosis ?. autopay
20 Was disease or Injury In any way related to occupation of deceased? Who If so, specify.
(Signed)
WB Osgood
M. D.
(Address)
Date 3/22/1940
21 PLACE OF BURIAL.
CREMATION OR REMOVAL(!Y
HolyCaso
DATE OF BURIAL
3/25/40
19
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
Maraton
Received and filed
19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 8427-f
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible ww ww yvus Vy of town it case the deceased resided in another city or town at the time
2 FULL NAME
Mary a. mcCann
(If deceased is a married, widowed or divorced woman, give also maiden name.)
20 Woodside PR.
St.
months
days.
(If nonresident, give lity or town and state)
In this community/Oyrs.
mos.
days.
63
119 I HEREBY CERTIFY. Ca 29 1940 3/22/40 19
h .. Aalive on ....
3/22/2019.
death is said
to have occurred on the date stated above, at .... 33300m
Duration Immediate cause of death. Hodgkins disease
Due to
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Underline the cause to which death should be charged sta- tistically.
Walken
(Cemetery)/
(City or Town)
PARENTS
3 60 Years
TOWA
12 1
7
6
5
HROP.
M
APR121940 M1
M R-302
PLACE OF DEATH
SUFFOLK BOCounty
(City or Town)
No. New England Hosp for W & C
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
ISTON [ City or town making return)
Registered No 3034
S (If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
-
2 FULL NAME
3 SEX
F
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
7 IF STILLBORN, enter that fact here.
Usual
9 Occupation:
Industry
10 or Business:
11 Social Security No.
13 NAME OF
FATHER
15 MAIDEN NAME
OF MOTHER
PARENTS
17
Informant.
H F Reinhard
(Address)
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
(State or country)
Mass
50m-10-'39. No. 8427-f
4 COLOR OR RACE: 5 SINGLE
MARRIED
W
WIDOWED
or DIVORCED
(write the word)
Widowed
(Give maiden name of wife in full)
Louis .... T .... Howard
(Husband's name in full)
6 Age of husband or wife if alive .Years!
8 ÅGE .. .6.9 .... Yoars Months. Days
If less than 1 day
Hours
Minutes
a.t .... home
12 BIRTHPLACE (City)
Boston
(State or country)
Mass
Ferdinand A Reinhard
14 BIRTHPLACE OF
FATHER (City)
Boston
Julia Wood
16 BIRTHPLACE OF
MOTHER (City)
Halifax
(State or country)
Nova Scotia
Relation, if any Brother
A TRUE COPY.
ATTEST:
James Q. Bunke
Registrar
/(Registrar of city or town where death occurred)
DATE FILED
4/3/40
.. 19.
18 DATE OF
DEATH
March 30 1940
(Month)
(Year)
(Day)
That I attended deceased from
I last saw h .. O.r ..... alive on.
3/30/40
to have occurred on the date stated above, at.
19 ...
., death is said
Duration
Immediate cause of death ..
Metastatic carcinoma
to liver
Due to Carcinoma of left breast
Due to
Other conditions
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Left mastectomy
carcinoma
Date of.Jan. 1937
Of autopsy
What test confirmed diagnosis ?
20 Was disease or lajury In any way related to occupation of deceased ?
If so, specify.
(Signed)
L B.Crowell
(Address) N E Hosp for W & C
Da3/30/4019
, M. D.
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
South Church Cem. Andover
(Cemetery)
(City or Town)
DATE OF BURIAL
22 NAME OF
FUNERAL DIRECTOR
C R Bennison
ADDRESS
Winthrop
Received and fled
apr 2 ml
19
(Registrar of City or Town where deceased resided)
(If U. S.
War Veteran,
specify WAR)
63
75 Somerset Avenue
St.
Winthrop
(a) Residence. No ...
(Usual place of abode)
Length of stay : In hospital or institution.
years
months
days.
(If nonresident, give city or town and state)
In this community5 yrs.
nos.
5
days.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
19 | HEREBY CERTIFY.
3/26/40
19
to ..
3 /30/40
19
PHYSICIAN
Underline the cause to which death should be charged sta- tistically.
4/2/40
19
1
Alice Howard
(If deceased is a married, widowed or divorced woman, give also maiden name.)
TOM !!!
11 12
9
in
8
6
HROF
APR121940 M
<
A R-302
3 SEX
male
(or) WIFE of
8
AGE
Usual
9 Occupation:
Industry
10 or Business:
16 BIRTHPLACE OF
PARENTS
MOTHER (City)
(State or country)
17
Informant.
(Address)
50m-10-'39. No. 8427-f
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
(State or country)
4 COLOR OR RACE 5 SINGLE
white
(write the word)
MARRIED
WIDOWED
or DIVORCED
separated
5a If married, widowed, or divorced HUSBAND of
(Give maiden baigje bof wife in)( 1 3
(Husband's name in full)
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
Months. Days
If less than I day Hours .. .Minutes
11 Social Security No ......... ne
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Morris Buddelof
14 BIRTHPLACE OF
FATHER (City)
...
15 MAIDEN NAME
OF MOTHER
Rosie ----
Cannot NO ICETEA
Relation, if any
Muckhilips(
A TRUE COPY.
-
ATTEST:
(Registrar'of city or town where death occurred)
DATE FILED 4/9/40
19
.............
.St.
(If Homesiatht, give' city or town and state)
(Specify whether)
years
months
dayg.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
April 1, 1940
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY.
That I attended deceased from
I last saw h ......... malive on .............. }}} ?............... , 19.
.... ,
death is said
to have occurred on the date stated above 10. 05 TO
om.
Immediate cause of death
Lobar ... pnoumonia ......
...
Duration 3/11/40
Due to
Due to
Other conditions
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of.
Of autopsy
What test confirmed diagnosis ?........... 3.2.2 .....
20 Was disease or Injury In any way related to occupatloo of deceased ?
no
If so, specify.
(Signed)
Nyer Aschot2
M. D.
.
(Address)
Date
19
4/5/40
21 PLACE OF BURIAL, . .. .
CREMATION OR REMOVAL
INVeTust deWARCemetery)
Avereily or Town)
DATE OF BURIAL
19
22 NAME OF
4/2/20
FUNERAL DIRECTOR Manuel .. Stano taky.
ADDRESS
Received and filed.
19
..........
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
D anders
(City or town making return)
Registered No
67
1 (If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
PLACE OF DEATH
Essex (County)
No ...... Danvers State Hospital
2 FULL NAME
Nathan But
(If deceased is a married, wasto Go
566 Shirley
Favorced woman, give also maiden name.)
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution ..
47
years
··· p ......................... , 19 ..... 40 .
PHYSICIAN
Underline the cause to which death should be charged sta- tistically.
(Registrar of City or Town where deceased resided)
CFFI
0
...
769
ROP.
ASS.
MAY-21960 K1
R-302
PLACE OF DEATH
Suffolk (County)
Chelsea (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Chelsea
(City or town making return)
Registered No ..
63
(If death occurred in a hospital or institution, Gt. ( give its NAME instead of street and number)
2 FULL NAME
Charles ......... Hinckley
(If deceased is a married, widowed or divorced woman, give also maiden name.)
203 MainSt
St.
Winthrop, Mass
Length of stay: In hospital or institution.
(Specify whether)
years
months
days1.7
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
(Day)
DEATH
anp11-3,1940
(Year)
19 I HEREBY CERTIFY.
That I attended deceased from
Har ...... 16 .~ 19 ..... 400.
A.pr ...... 2.9.
.....
19
40
I last saw h ....... A.olive on .. 3.y., 19 ....... 4 death is said to have occurred on the date stated above, at ...... 5 .;. 1.7.40. Immediate cause of death .. Duration Unemia.
2 das
Due to
Arterio-sclerotic kidney
disease
Due to
Generalized ... arterio ..
sclerosia.
?
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
nono
Underline the cause to which death
Of autopsy
none
should be charged sta-
What test confirmed diagnosis ?
Yes .... JIP.N.
....
tistically.
20 Was disease or Injury In any way related to occupation of deceased ?
If so, specify
Isadoro Kaplan
(Signed)
(Address)
Soldiers Home
Dato
M. D.
49
40
21 PLACE OF BURIAL, CREMATION OR REMOVAL. WinthropCem.Winthro] (Cemetery) DATE OF BURIAL Apr. 5, 1920°r Town) .19 .... FUNERAL DIRECTOR Albert F. Douglass
22 NAME OF
ATTEST:
(Registrar of city 'or towe'shere death pccursed)
Apr.
194Received and filed
Apr. 0, 1940"
19
(Registrar of City or Town where deceased resided)
wwwwitu ju your city of town in case the deceased resided in another city or town at the time
3 SEX
Male
white
5a If married, widowed, or divorced
HUSBAND of
(Give Mardel
(or) WIFE of
6 Age of husband or wife if alive
63
8
AGE
68Ye
7 Months.
.8 Days
Industry
Il Social Security No.
none
12 BIRTHPLACE (City)
Boston
(State or country)
13 NAME OF
FATHER
Charles A.
14 BIRTHPLACE OF
FATHER (City)
Wellfleet
PARENTS
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
17
Hospital Records
Informant.
(Address)
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
(State or country)
Mass
50m-10-'39. No. 8427-f
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
married
(Husband's name in full)
.. years 7 IF STILLBORN, enter that fact here.
If less than I day
Hours
Minutes
Usual
9 Occupation:
Retired.Fireman
10 or Business:
(City of Chelsea)
15 MAIDEN NAME
OF MOTHER
Clare Anderson
East Boston
Mass"
Relation, if any
A TRUE COPY.
ADDRESS
Chelsea, Mass.
DATE FILED
1
No Soldiers !.... Home ... Hospital
(If U. S.
War Veteran,
specify WAR)
Spanish
(a) Residence. No ...
(Usual place of abode)
Hospital
(If nonresident, give city or town and state)
.Date of.
7
M R-301 A! Suffolk (County) Whichit
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD
To be filed for burial permit with Board of Health or its Agent.
Registered No .. 69
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