USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1940 > Part 59
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No undertaker or other person shall bury a human hody or the ashes thereof which have been hrought Into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be huried or the funeral Is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made .... Chap. 114. Sec. 46, G. L. as amended.
Medical examiners shall make examination upon the view of the dead hodies of only such persons as are supposed to have died hy violence. If a medical examiner has notice that there is within his county the hody of such a person, he shall forthwith go to the place where the body lies and take charge of the same; ... - General 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 he, with the cause and man- ner of death .- General Laws, Chap. 38, Sec 7.
. The medical examiner certifies the cause and manner of death to the best of his knowledge and belief.
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 Health physicians will certify to such deaths only as those of persons who, though disabled hy recognized disease un- related to any form of injury, have died without recent medical attendance or whose physician is ahsent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly hy traumatism (including resulting septice- mia), and hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, hut also deaths from disease resulting from injury or infection relaled to occupa- tion, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause, the nature of an injury and of its consequences ; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused hy a steam railway ac- cident." "Pistol shot wound of the chest with associated hemor- rhage, homicidal." "Asphyxiation hy suspension, suicidal." "Syn- cope while under the influence of ether administered as a surgical anaesthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If inves- tigation shows the death to have heen due to disease. specify: (1) Under cause, its known or presumahle nature ; and (2) under man- ner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous, of the hrain (hasal ganglia) (found dead In bed)." "Heart disease, presumably coronary sclerosis. (Sudden death)."
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have met his death by violence, until a permit, signed by the Medical Examiner, has first been obtained .- General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
-302
MIDDLESEX
(County)
TEWKSBURY
TEWKSBURY
BURY STATE HOSPITAL and INFIRMARY
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
TEWKSBURY STATE HOSPITAL and INFIRMARY TEWKSBURY
(City or town making return)
Registered No.
304
(If death occurred in a hospital or institution, give its NAME instead of street and number) 0002.00
2 FULL NAME
Russell ... W ...... Hook
(If deceased is a married, widowed or divorced woman, give also maiden name.)
56 Locust
St.
Winthrop
(If nonresident, give city or town and state)
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX Male
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
White
Single
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
years
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
8 AGE43 Years. 7 Months. 22Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation:
Dependent
Industry 10 or Business:
11 Social Security No. None
12 BIRTHPLACE (City)
East Boston
(State or country)
Mass.
13 NAME OF
FATHER
Dudley Hook
14 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass
15 MAIDEN NAME
OF MOTHER
Emma Battis
16 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country) Mass
17 HOSPITAL RECORDS
Relation, if any
Informant
(Address)
A TRUE COPY.
ATTEST:
Dansnce . Shelley M. Sup.
(Registrar of city or town where death occurred)
DATE FILED Sept. 2, 19 40
18 DATE OF
DEATH
Sept.
2.
1940
(Month)
(Year)
(Day)
That I attended deceased from
19 I HEREBY CERTIFY.
Aug ...... 27
19 .. 40
to
Sept. 2
19 .. 40
I last saw h.l.m .... alive on
Sept. 2, 1940, death is said
to have occurred on the date stated above, at. 2:35P .m.
Duration
Immediate cause of death ..
Disseminated Sclerosis
unknown
Due to
Due to
2 .... da.
Other conditions Terminal Broncho-pneumonia PHYSICIAN (Include pregnancy within 3 months of death)
Major findings :
Of operations
Underline the cause to which death
Of autopsy
What test confirmed diagnosis ?.. Clinical
should be charged sta- tistically.
20 Was disease or Injury In any way related to occupation of deceased ?
If so, specify.
(Signed)
C.W. Houghton
M. D.
(Address)
T.S.H.& I., Tewksbury
Date
9-2 ..... 19 40
21 PLACE OF BURIAL. CREMATION OR REMOVAL ... Mayflower, (Cemetery) (City cr Town)
DATE OF BURIAL
Sept. 4,
19.40
22 NAME OF
FUNERAL DIRECTOR
Charles R .Pennison
ADDRESS
170 Winthrop St., Winthrop
Received and filed.
19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 8427-f
PLACE OF DEATH
No ..
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
5
days.
In this community
yrs.
Copies ofreturns of deaths muchoournd in vous fyre r . d . , a after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
PARENTS
.Date of.
Duxbury
NOV SON TM
12-302
1
PLACE OF DEATH
MIDDLESEX (County) NEWTON (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
NEWTON (City or town making return)
Registered No ... 540 ...
(If death occurred in a hospital or institution, give its NAME instead of street and number)
201
2 FULL NAME
(If deceased is SEarata, widowed or livort @ to@ live also maiden name.)
.....
St.
(a) Residence. No .......... ].6.6
(Usual place of abode)
Bartlett Road
Length of stay: In hospital or institution ...
(
years
months
days 2
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
White
Single
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
years
S Age of husband or wife if alivo.
7 IF STILLBORN, enter that fact here.
8
AGE
Years
.Months.
Days
If less than 1 day
Hours
Minutos
Usual
9 Occupation:
Kurse
Industry
10 or Business:
Household
11 Social Security No .....
021-16-7583
12 BIRTHPLACE (City)
(State or country)
Liverpool
England
13 NAME OF
FATHER
Henry F Letson
14 BIRTHPLACE OF
FATHER (City)
Chatham
(State or country)
# B
15 MAIDEN NAME
OF MOTHER
Eliza Letson
IS BIRTHPLACE OF
MOTHER (City)
(State or country)
Chatham-
17 Informant (Address)
Relation, if any
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
Oct
14 19
40
18 DATE OF
DEATH
C.c.t .............
1940
(Month)
19 | HEREBY CERTIFY.
C.c.t ........ 7 ..... , 19.
.HOto.
(Day)
(Ycar)
That I attended deceased from
O.c.t.
.....
9
19 40
I last saw h ...... C.Ialive on ..... Oct, 99 4Death is said to have occurred on the date stated above, at 7: 43 pm. Duration Immediate cause of death. Intestinal ... Obstruction
10/4/40
Due to
.Adhesions
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Phpperations
Intestinal Obstruction
Of
Date of Oct 7 19 High death
Of autopsy
What test confirmed diagnosis ?.
X-Ray
tistically.
20 Was disease or injury in any way related to occupation of deceased ?
NO
If so, specify
(Signed)
Herbert G Munphy
M. D.
(Address)
19
21 PLACE OF BURIAL, Boston Mass CREMATION OR REMOVAL.
10/9 40
James M Letson ....... ( Brother inthrop Cemeteryy) Winthrop fees 59 Imleside ave-Winthrop DATE OF BURIAL tet 11
N&B P22 NAME OF
FUNERAL DIRECTOR
Richard White
ADDRESS
Winthrop Mass
1940
Received and filed.
Nov. 15
DONALD S. Mc LEOD
(Registrar of City or Town where deceased resided)
errad in went city ar tour in anca IL_ J
Copies of returns of deaths which after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
50m-10-'39. No. 8427-f
PARENTS
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
(If U. S. War Veteran, specify WAR)
Pe chy br"town and state)
Underline
should be charged sta-
Dato
19 40
No. "Newton Hospital
TO!
OF
-
6
FRAP.
12-302
1
PLACE OF DEATH
SUFFOLK Com BOSTON
(City or Town)
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.
8718
{ (If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME
Annie
(If deceased is a married, widowed or divorced woman, give also maiden name.)
148 Shore Drive
St.
(If U. S.
War Veteran,
specify WAR)
1
Winthrop
(a) Residence. No ..
(Usual place of abode)
Length of stay: In hospital or institution.
years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
fem
4 COLOR OR RACE 5 SINGLE
white
MARRIED
WIDOWED
or DIVORCED
(write the word)
married
18 DATE OF
DEATH
Oct 11 1940
(Month)
(Day)
(Year)
5a lf married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Samuel ...... Kline.
(Husband's name in' full)
19 | HEREBY CERTIFY.
10/9/40
19
.. , to ..
I last saw h ........... alive on.
10/11/40
19
.......
death is said
6 Age of husband or wife if alive
62
years
7 IF STILLBORN, enter that fact here.
Immediate cause of death.
coronary occlusion
abt 3 dys
cerebral accident (prob embolis )2 dy:
Due to
with right hemiplegia
Industry
10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
Russia
(State or country)
13 NAME OF
FATHER
Bernard Sundler
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Rus.s.18 ...
15 MAIDEN NAME
OF MOTHER
Katie -
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17 Julius M
Relation, if any ... (.8.on
A TRUE
corr francis
ATTEST:
5 Tay
(Registrar of city or town where death occurred)
DATE FILED
10/15/40
19
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Date of.
Underline the cause to which death
Of autopsy
What test confirmed diagnosis ?.
20 Was disease or Injury In any way related te occupation of deceased ?
If so, specify
(Signed)
CC Bailey
M. D.
(Address).
Boston
Date0/11/19 40
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Beth Israel W Rox
DATE OF BURIAL.
Oct 13 1940
19
22 NAME OF
FUNERAL DIRECTOR
J H Levine
ADDRESS
Boston
Received and filed 19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 8427-f
Copies of returns of deathe after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
Voir Alto Ao but tint city of Luwir nf with the ueceastu residea as soon as possible
h
PARENTS
If less than 1 day Hours. Minutes
Usual
9 Occupation:
at home
Due to
Duration
8
64
AGE
Years
.Months.
Days
to have occurred on the date stated above, at.
12/55₽
That I attended deceased from
10/11/40
19.
......
(If nonresident, give city or town and state)
(Specify whether)
Kline
202
No. N .... E ... Deaconess .... Hospital
-
Informant.
(Address)
(Cemetery)
(City or Town)
should be charged sta- tistically.
٠٠٠
R-301 A: Suffolk County Withupp (City or Town)
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. 203
Registered No. (If death occurred in a hospital or institution, give its NAME instead of street and number)
(If U. S. War Veteran, specify WAR).
Winthrop
(If nonresident, give city or town and state)
Length of stay: In hospital or institution .... (Specify whether)
years
months
days.
In this community
16 yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE
MARRIED
WIDOWED
Or DIVORCED
(write the word) Dyanes
(Give maiden rame of fife in full)
(Husband's name in full)
55 years
If less than 1 day
Hours
Minutes
Houseinfe
Russia
13 NAME OF FATHER Solomou Ginsberg
Pussige
Hreda - Cannotbe
Rusia
Relation, if any 21
1
I HEREBY CERTIFY that a satisfactory, standard certificate. of death was filed with me BEFORE the bunch or transit permil wau issuecop Nu. D- Children (Signature of Agentsof Board Health or othery We alter oficer 1 11/2/40 (Date of Issue of Permity (Official Designation)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
november 1,
(Month)
Day)
1440
(Year)
19 I HEREBY CERTIFY That I attended deceased from July 12, 1932 .. , to .. 19 40 9 last saw her alive on Nov/ ..... 19. .. death is said to have occurred on the date stated above, at 12:53 ..........?. M.
Duration
Immediate cause of death
Cerebral lemandar eller 11/1/40
...
IMPORTANT
... 3 yrs
Hy pertensing Heart Winter 3 yrs
Due to
Other conditions (Include pregnancy within 3 months of death)
Major findings : Of operations
Date of.
Of autopsy
What test confirmed diagnosis ?
PHYSICIAN Underline the cause to which death should be charged sta- tistically.
Was disease or Injury in any wszy related to occupation af deceased?
It so, specify
y a Nathan Caplan
M. D.
(Signed).
Date .. 11/1 1940
(Address) 186 Princekunsten Winthrop Place of Burial, Cremation or Removal. DATE OF BURIAL 5- 19.VE (Sity lor Town)
nov
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
10-
Work 9.40.
Received and filed
19)
(Registrar)
100m-10-'39. No. 8427-e N. B .- WRITE PLAINLY, WITH ONFADING BLACK INK - THIS IS A PERMANENT RECORD PARENTS
PLACE OF DEATH
26- Honest
St. {
2 FULL NAME
Rose Pikew
(If deceased is a married, widowed or divorced woman, give also maiden name.)
26- Honest
.....
St.
1 No. (a) Residence. No. (Usual place of abode) 3 SEX 4 COLOR OR RACE Finale white 5a If married, widowed, or divorced HUSBAND of (or) WIFE of 6 Age of husband or wife if alive 7 IF STILLBORN, enter that fact here. 8 AGE Years Months. .Days Usual 9 Occupation: 11 Social Security No. 12 BIRTHPLACE (City) (State or country) 14 BIRTHPLACE OF FATHER (City) (State or country) 15 MAIDEN NAME OF MOTHER 16 BIRTHPLACE OF MOTHER (City) (State orcountry) 17 Israel Piker Informant. (Address) 26 - Honor CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION Industry 10 or Business: of Home is very important. See instructions and extracts from the laws on back of certificate.
.tam
Due to
Hypertensem
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 regls- tration a standard certificate of death, stating to the best of his knowledge and bellef the name of the deceased, his supposed age, the discase of which he died, defined as required hy 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. 43. Sec. 9.
No undertaker or other person sball bury or otherwise dispose of a human hody in a town, or remove thercfrom 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 tomh other than the receiving toinb to another in the same cemetery, until he has received a permit from the hoard of health or its agent aforesaid or from the clerk of the town where the body is hurled. No such permit shall be issued until there shall have been de- livered to such hoard, agent or clerk, as the case may be, a satisfac- tory written statement containing the facts required by law to be returned and recorded, which shall be accompanled, 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 physiclan who is a member of the board of health, or employed hy 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 exanı- 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 carly enough for the purpose, the certificate of death mnade 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 hercunder. If the death certificate contalns 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 transmlt it to the clerk of the town for registration. The person to whom the permit is so given and the physiclan certifying the cause of death shall thereafter for- nish for registration any other necessary information which can be ohtained 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 hrought Into the commonwealth until he has received a permit so to do from the board of health or its agcut appointed to issue such permits, or If there Is no such board, from the clerk of the town where the body Is to be hurled 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., (Torcentenary 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 bedelde 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 hy 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 septlee- 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 occupn- tion, the sudden deaths of persons not disabled by recognised diseaso, and those of persons found dead.
Statement of Canse 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 eausing death. As related causes, name earller morbid con- ditions, if any, related to the principal cause and any important complication of the principal cause.
, Statement of Occupation .- Precise statement of ocenpation 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 nsual 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 housakesper-private family, cook-hotel, ete. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
2-301 A
PLACE OF DEATH
Suffolk County)
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.
204
Registered No.
§ (If death occurred in a hospital or institution, { give its NAME instead of street and number)
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
21. Emer
erson
Roads
(If nonresident, give city or town and state)
.years
months < days.
In this community
yrs.
mos.
< days.
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)
WidusedDEATH
(Month)
(Day)
1940 (Year)
Mar
HEREBY CERTIFY, 193.1. to .. nov 19
That I attended deceased from 80
mor 19 death is said to I last saw h walive on 9.10 have occurred on the date stated above, at.
.m. Immediate cause of death. Coronary recluen
Duration IMPORTANT 11-2-8
1927
IMPORTANT
PHYSICIAN
Major findings: Of operations.
Of autopsy.
What test confirmed diagnosis? B.P. History.
20 Was disease or injury in any way related to occupation of deceased ?.
If so, specify
M. D.
(Signed)
64 Beach St Werd
Date 11-4 1920
21
Place of Burial, Cremation or Removal.
DATE OF BURIAL
200
& (City or Town)
10mm
19 40
........
22 NAME OF FUNERAL DIRECTOR ADDRESS
Received and filed
19
(Registrar)
DUVCIATAMO un lu pi terms, so that it may be properly cassine. Exact statement of OCCUPATION Là Số.La GYACTIV
information should ha carefully ausculind is very important. See instructions and extracts from the laws on back of certificate.
100m-2-'40-D-729-a
I7
Relation, if any
Informant (Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Nus. Children. (Signature of Agent of Board of Health or other)
Realit oficer 11/4/40
(Official Designation) (Date of Issue of Permit)
18 DATE OF
5a If married, wid wed HUSBAND of.
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive ..
2 2 .years
7 IF STILLBORN, enter that fact here. 2
-
8
76
Years
24 Days
If less than I day
Hours.
Minutes
9 Occupation :
Rebutt
Industry
10 or Business:
Il Social Security No ...... Novia Scotia
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
John . Kent
PARENTS
14 BIRTHPLACE OF
FATHER (Cny)
....
(State or country)
nova Scotia
15 MAIDEN NAME
OF MOTHER
Jarah Williams
16 BIRTHPLACE OF
MOTHER (City).
(State or country)
Nova Scotia
I
(City or Town) # 21 Emissor No. albert.
Rent
St.
(If U. S. War Veteran, specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
2
Due to. Generalize dartin- petersen
Due to
Other conditions. (Include pregnancy within 3 months of death)
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