Town of Winthrop : Record of Deaths 1940, Part 23

Author: Winthrop (Mass.)
Publication date: 1940
Publisher:
Number of Pages: 494


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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