Town of Winthrop : Record of Deaths 1940, Part 59

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1940 > Part 59


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


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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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