USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1940 > Part 23
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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, Ses. 46, G. L., (Tercentenary Edition)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observ- ance of the following rules of practice :
(1) Altending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last ill- ness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease un- related to any form of injury, have dicd without recent inedical 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 lo injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septice- mia), 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 occupa- tion, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Stalemeni of Cause of Death .- Cause of death means the disease, or complication which causes death, not the niode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease causing death. As related causes, name earlier morbid con- ditions, if any, related to the principal cause and any important complication of the principal cause.
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 busi- ness, report the usual 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. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekecper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
IR-302
PARENTS 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 PartyW Tw yvat city of town in case the deceased resided in another city or town at the time 8 AGE
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.
(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME
(Ii deceased is a married, whoted HERyer
woman, give also maiden name.)
(If U. S. War Veteran, specify WAR)
Spanish
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution ..
(Specify whether)
19.3 .... River .... Rd.
..... St.
Winthrop, Mass.
Hospital
months
days.
15
(lf nonresident, give city or town and state)
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE 5 SINGLE
white
MARRIED
WIDOWED
or DIVORCED
(write the word)
married
5a If married, widowed, or divorced
HUSBAND of (Give maiden name of wife in Tull)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive.
years
If less than 1 day Hours Minutes
Usual
9 Occupation:
Salesman
Industry
10 or Business:
Egg Business
11 Social Security No.
12 BIRTHPLACE (City)
Portland
(State or country)
13 NAME OF
FATHER
Benjamin F. Sawyer
14 BIRTHPLACE OF
Bridgton
FATHER (City)
(State or country)
Maine
15 MAIDEN NAME
OF MOTHER
Mary A. Hannon
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Hospital Records Relation, if any
Informant.
(Address)
A TRUE COPY.
ATTEST:
DATE FILED .....
Apr . 00 1940
18 DATE OF
DEATH.
40611-10,
, 1940
(Đầy)
(Year)
19 I HEREBY CERTIFY. That I attended deceased from .Men ...... 26 .. , 19 ........ Q ....... A.p.r ........ 10., .... de@h is said .. , 19 .. 4.0 I last saw h ............ Alive on ............. A ............ 1.019 .. .... , to have occurred on the date stated above, at ...... 9.1.432. Duration Immediate cause of death ....... Gar.11.80 ... decom pensation
Due to ..... Myocardial Dogoneration .. Arteriosclerosis
¿........ over
3 .... yrs
Due to
Other conditions
Ve.l.vular .... heart .... d.i.sGAffeIAN
(Include pregnancy within 3 months of death)
Serological ... syphilis
Major findings :
Of operations
nono
Date of
Of autopsy
none
What test confirmed diagnosis ?. clinical
20 Was disease or Injury In any way related to occupation of deceased ? no
If so, specify.
(Signod)
W.H.Blanchard
. M. D.
(Address)
Soed . Homeloso. . Date.
4 109 .40
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Inthrop.,
inthrop., Ma:
(City or Town)
DATE OF BURIAL
Apr. 13, 1940
22 NAME OF
FUNERAL DIRECTOR
John F. O'Maley
ADDRESS
Winthrop, Mass.
Received and filed Apr.10.191940
(Registrar of City or Town where deceased resided)
yr
over
Underline the cause to which death should be charged sta- tistically.
(Cemetery)
-
No Chelsea Soldfors-Hom
1
7 IF STILLBORN, enter that fact here.
Months. Days
Alice .F. Loakop ...
15 .... das.
IR-302
1
PLACE OF DEATH
BOSTON (City or Town)
No. 320 Walnut Avenue
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.
3448
5 (If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
Sarah Taylor
(If deceased is a married, widowed or divorced woman, give also maiden name.)
37 Myrtle Avenue
..........
............
St.
Winthrop
(a) Residence. No ..
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
years
7
months
days.
In this community 15yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
April 11, 1940
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY.
That I attended deceased from
viewed
19
I last saw h ...
.. alive on ..
.....
to have occurred on the date stated above, at.
.. m.
Duration
Immediate cause of death.
Cerebral hemorrhage
unknown .......
Due to
Due to
unknown
Other conditionsGeneral arteriosclerosis (Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Underline the cause to which death
Of autopsy
What test confirmed diagnosis ?
20 Was disease or Injury In any way related to occupation of deceased ? If so, specify
(Signed)
F J Bailey
M. D.
(Address)
Deputy Health .Com. Dato 4 /11 1940
21 PLACE OF BURIAL,
CREMATION OR REMOVAL David Vieur Cholim, W. Kof
(Cemetery)
(City or Town)
DATE OF BURIAL
4/12/40
19
22 NAME OF
FUNERAL DIRECTOR
B Schlossberg & Sons <
ADDRESS
Boston
Received and filed.
19
(Registrar of City or Town where deceased resided)
14-61-3 . 2 per al call
2 FULL NAME
3 SEX
F
W
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:
Il Social Security No.
none
15 MAIDEN NAME
OF MOTHER
PARENTS
17
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
wave if yout chy of town in case the deceased resided in another city or town at the time
8
AGE
.7.5Years
Months.
Days
50m-10-'39. No. 8427-f
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
(Give maiden name of wife in full)
George Taylor
(Husband's name in full)
6 Age of husband or wife if alive.
73
.years
If less than I day Hours. Minutes
housewife
at home
12 BIRTHPLACE (City)
(State or country)
England
13 NAME OF
FATHER
Abraham Levy
14 BIRTHPLACE OF
FATHER (City)
(State or country)
England
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
George Sayers (
Relation, if any Son
A TRUE COPY.
ATTEST:
James C.C Brani
(Registrar of city or town where death occurred)
DATE FILED
4/13/40
19
(If U. S.
War Veteran,
specify WAR)
(If nonresident, give city or town and state)
19.
.. , to.
19
death is said
Date of ..
should be charged sta- tistically.
1 R-301 A|
PLACE OF DEATH
Suffo.l ...
(County)
Tinthron
(City or Town)
No. 507 Shirley St
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 (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Agatha Veronica Conti
(If deceased is a married, widowed or divorced woman, give also maiden name.)
507 Shirley St.
............
St.
(If nonresident, give city or town and state)
days.
In this community 95 yrs.
mos.
days.
23
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
12
1940
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
19 ...
.. ,
to
That I attended deceased from 1
I fast saw him alive on ..
19 ..
death is said
to have occurred on the date stated above, at.
6:407
.m.
Duration
IMPORTANT
Immediate cause of death.
Natural Cours , Probably
Due to
apr. 12 1440
Usual
9 Occupation:
Am Home
1I Social Security No.
12 BIRTHPLACE (City)
South Braintree
(State or country)
Massachusetts
13 NAME OF
FATHER
Mario Conti
14 BIRTHPLACE OF
FATHER (City) Sicily
(State or country) Italy
15 MAIDEN NAME
OF MOTHER
Nunzia Tomassello
Messina
16 BIRTHPLACE OF MOTHER (City) (State or country) Italy
17 Mario Conti Informant. (Address) 507 Shirley St. Winthrop
Relation, if any Father
I HEREBY CERTIFY that a satisfactory standard certificate of death was Eled with me BEFORE the burial or transit permit was issued: Wm.D. Childress
(Signature of Agent of Board of Health or other)
H.O. april.15/40-
(Official Designation) Date of Issue of Fernfit)
20 Was disease or Injury in any way related to occupation of deceased?
(Signed).
Pamat B Parker
M. D.
(Address) Winthrop Brand of Health
Date Ch. 14 1940
21 Holy Cross
Kalder
Place of Burial, Cremation for Removal. 75 (City or Town) 40
DATE OF BURIAL
19
22-NAME OF
FUNERAL DIRECTOR
ADDRESS
linthrop Mass.
John STO maley
Received and filed ..
19
(Registrar)
100m-10-'39. No. 8427-e
1 3 SEX Female (or) WIFE of 8 PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and extracts from the laws on back of certificate. information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state Industry 10 or Business:
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
years
6 Age of husband or wife if alive. 7 IF STILLBORN, enter that fact here.
If less than I day
ÄGE
24
Years
Months
Days
Hours
Minutes
Due to
Other conditions
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of.
Of autopsy
no
What test confirmed diagnosis? hurtigaten
·
PHYSICIAN Underline the cause to which death should be charged sta- tistically.
St. 1
(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
19
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, 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 regis- tration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death ... Gen. Laws, Chap. 46, Scc. 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 de- livered to such board, agent or clerk, as the case may be, & satisfac- tory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the pur- pose, shall upon application make the certificate required of the at- tending physician. If death is caused by violence, the medical exam- iner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another 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 removal shall constitute a permit for such removal ; provided, that such body shall be returned to the town from which it was removed within thirty- six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the death certificate contains a recital, as required by section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registration. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter fur- nish 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., (Tercentenary Edition.)
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., (T'ercentenary Edition)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observ- ance 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 ill- ness from disease unrelated to any form of injury.
(2) Board of Ilealth physicians will certify to such deaths only as those of persons who, though disabled by recognized disease un- related to any form of injury, have died without recent medical 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 septice- mia). 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 occupa- tion, the sudden deatha of persons not disabled by recognized disease, and those of persons found dead.
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 con- ditions, if any, related to the principal cause and any important complication of the principal cause.
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 busi- ness, report the usual 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. 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.
SPACE FOR ADDITIONAL INFORMATION
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
PLACE OF DEATH
(County)
Boston
(City or Town)
No. 818 Harrison Avenue
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON (City or town making return)
Registered No
3524
(If death occurred in a hospital or institution, St. give its NAME instead of street and number)
2 FULL NAME
George R Robinson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
21 Grover Avenue
.St.
(If nonresident, give city or town and state)
In this community 2grs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX M
4 COLOR OR RACE 5 SINGLE
MARRIED
W
WIDOWED
or DIVORCED
(write the word)
Widowed
Sa If married, widowod, or divorced
HUSBAND of
Susan E Perkins
(Give maiden name of wife in full)
(or) WIFE of ...
(Husband's name in full)
Years
8 AGE .... 63. ... Years. Months. Days
Il less than I day
Hours
Minutes
Usual 9 Occupation:
Shi pper
Industry 10 or Business:
leather business
II Social Security No.
031-03-7732
12 BIRTHPLACE (City)
Gloucester
(State or country)
Mass
13 NAME OF
FATHER
Richard Robinson
PARENTS
14 BIRTHPLACE OF FATHER (City)
(State or country) England
15 MAIDEN NAME OF MOTHER Emaline -
16 BIRTHPLACE OF MOTHER (City) (State or country) England
17
Informant
W S Robinson
(Address)
Relation, if any (Brother Q.0Punti
A TRUE COPY.
ATTEST:
James
(Registrar of gity or town where death occurred)
DATE FILED
4/16/40
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
April 12, 1940
(Month)
(Day)
(Year)
19 I 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.) Coronary solerosis Hospitalised for coronary thrombosis in 1939
20 Accident, suicide, or homicide (specify).
Date of occurrence. 19
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 ?
Mannor of
(Specify type of place)
Injury
Collapsed on street
Nature of Injury
While at work ?
Was there an autopsy?
21 Was disease or injury le any way related to occupation cf deceased ?.
If so, specify
(Signed)
T Leary
M. D.
(Address).
Boston
Date 4/12/40
22 .. Mt. Pleasant-Gloucester.
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
4/15/40
.19
23 NAME OF
FUNERAL DIRECTOR
J F O'Maley
ADDRESS
Winthrop
Roceived and filed 19
(Registrar of City or Town where deceased resided)
(If U. S. War Veteran, specify WAR)
125
(a) Residence. No ......
(Usual place of abode)
Length of stay: In hospital or institution.
years
(Specify whether)
Winthrop
months
days.
6 Age of husband or wife if alive.
7 IF STILLBORN, enter that fact here.
1
IR-302
PLACE OF DEATH
SURTOLK ( BCS (County)
(City or Town)
No. Long Island Hospital
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.
3507
5 (If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME Morris Trieger
(If deceased is a married, widowed or divorced woman, give also maiden name.)
38 Underhill
St.
Winthrop
(a) Residence. No ..
(Usual place of abode)
Length of stay: In hospital or institution ..
(Specify whether)
hospital
years
months
142d8.
In this community
50Yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
April 12, 1940
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY.
3/28/40
19
.. ,
to ........
That I attended deceased from
4/12/40
19
...
I last saw h .. i.m .... alive on
4/12/40
19
.... , death is said
to have occurred on the date stated above, at.1 .: 12 P m.
Duration
Immediate cause of death .. Dissecting ... aneurysm of abdominal aorta with
perforation - terminal
Due to Generalized arteriosclerosis
yr.s
Due toArteriosclerotic ... heart ... disease ... yrs Hypertensive cardio-pasuclar disease-yrs
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings : Of operations
Underline the cause to which death
Of autopsy
What test confirmed diagnosis ?.
.autopsy
20 Was discase er injury in any way related to occupation of deceased ? If so, specify.
(Signed)
C. L. Clay
(Address) .... Long Island ... Hosp
Dato.4/13/40
M. D.
21 PLACE OF BURIAL,
CREMATION OR REMOVAL .... Beth Israel-Everett.
(Cemetery)
(City or Town)
DATE OF BURIAL
4/14/40
19
22 NAME OF
FUNERAL DIRECTOR
M .... Stanetsky
ADDRESS
Boston
Received and filed
19
(Registrar of City or Town where deceased resided)
3 SEX
M
W
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
7 IF STILLBORN, enter that fact here.
8
AGE.
Years
8
.Months.22 .... Days
Il Social Security No.
none
12 BIRTHPLACE (City)
(State or country)
Austria
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Austria
15 MAIDEN NAME
OF MOTHER
Bella
16 BIRTHPLACE OF
PARENTS
MOTHER (City)
(State or country)
Austria
17
Informant
Long Island Hosp
(Address)
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
wwwwww Weight veculicu id your chy of town in case the deceased resided in another city or town at the time
Industry
10 or Business:
for himself
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
DIVORCED Widower
(write the word)
Katie .... Wolf
(Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if alive. .years
If less than I day Hours Minutes
Usual
9 Occupation:
salesman-pictures
13 NAME OF
FATHER
Israel Trieger
Relation, if any
A TRUE COPY.
ATTEST:
James Q. Branche
/(Registrar of city or town where death occurred)
DATE FILED
4/16/40
19
.....
(If nonresident, give city or town and state)
(If U. S. War Veteran, specify WAR)
2
Date of.
should be charged sta- tistically.
1 R -301 A |
Juffolk
(County)
intoron
(City or Town)
inthron Com .: undt -
osnital
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