USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1940 > Part 7
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Lawrence Cousine
14 BIRTHPLACE OF
FATHER (City)
(State or country)
St John
15 MAIDEN NAME
OF MOTHER
Ellen Nugent
16 BIRTHPLACE OF
MOTHER (City)
St. John
(State or country)
17 Newfoundland
Relation, if any
A TRUE COPY.
150 Circuit Ha Winthrop
ATTEST:
Jan 1.6 1940
(Registrar of city or town where death occurred)
DATE FILED Fasterich H Burke 19
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
none
Date of ..
should be charged sta- tistically.
Of autopsy What test confirmed diagnosis ? Thys Exam
20 Was disease or Injury in any way related to occupation of deteast ??
If so, specify. no
M. D.
(Signed)
(Address)
Christopher E Igan
19
21 PLACE OF BURIALS8 Rx
CREMATION OR REMOVAL upalo Rd Bel. 1/14 40
19
Informant ....
(Address)
Helen Cousin
( ...
daughter
DATE OF BURIAL
Holy cross
Mala Et or Town)
Jan 16
-1940
22 NAME OF
FUNERAL DIRECTOR
John F-O-Marley
ADDRESS
Winthrop
Received and filed
19
(Registrar of City or Town where deceased resided)
V
we Tung a due to the clerk of the city of town in which the deceased resided as soon as possible
50m-10-'39. No. 8427-f after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) PARENTS
...
Hypostatic Pneumonia
1wk
Due to
Chronic Myocarditis
Chronic Puesivo congestive-yr
Due to
I last saw h .......... dative on .......... J.a. 13 19 ...... 4 Death is said to have occurred on the date stated above, at ......... 5 ........ m. Duration Immediate cause of death ..
6 Age of husband or wife if alive
Widowed 19 I HEREBY CERTIFY.
That I attended deceased from
19.
40
Jan ... 12
.....
... , 19 ..... 50
Underline the cause to which death
Newfound land
(If U. S. War Veteran, speciiy WAR)
(a) Residence. No .. (Usual place of abode) 145 Bartlett Rd.
FEB161940 MM
R-302
PLACE OF DEATH
(County)
1
(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. 19
ยง (If death occurred in a hospital or institution, St. give its NAME instead of street and number)
2 FULL NAME
Baby Amarena Girl
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ...
71 Paine Street
St. Winthrop ....... MASS.
(Usual place of abode)
Length of stay: In hospital or institution
(Specify whether)
years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX female
4 COLOR OR RACE| 5 SINGLE
MARRIED
white
WIDOWED
or DIVORCED
(write the word)
single
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive. years
7 IF STILLBORN, enter that fact here.
stillborn
8
AGE
Years
Months.
Days
If less than 1 day Hours. Minutes
Usual
9 Occupation:
Industry 10 or Business:
II Social Security No.
12 BIRTHPLACE (City)
Boston
(State or country)
Mass.
13 NAME OF
FATHER
Domenick Amarena
14 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass.
15 MAIDEN NAME
OF MOTHER
Mary Dente
16 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass.
Relation, if any
Domenick Amarena ( Father
A TRUE
ATTEST:
James Q.Burke
(Registrar of city or town where death occurred)
DATE FILED
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Jan
20
1940
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY.
That I attended deceased from
I last saw h ............ alive on ..
............
to have occurred on the date stated above, at ...
.......... m.
Daration
Immediate cause of death.
Premature
Stillborn
(6 months).
Due to
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Of autopsy
What test confirmed diagnosis ?.
20 Was disease or Injury in any way related to occupation of deceased ?
If so, specify
T. V. Canepopia
(Signed)
M. D.
(Address).
195 Bay State
Date
1/20
.1940
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
Mt. Benedict Cem.
(Cemetery)
Boston(City or Town)
DATE OF BURIAL
Jan 22
22 NAME OF
FUNERAL DIRECTOR
Thomas D. Russell
ADDRESS
1409 Dor. Ave. Dor
Received and filed.
Jan .... 23, ..... 1940
19
(Registrar of City or Town where deceased resided)
w wie Wein of ruc chy of town ff which the deceased resided as soon as possible
50m-10-'39. No. 8427-f after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) PARENTS
NoAudubon ... Hospital
(If U. S.
War Veteran,
specify WAR)
(If nonresident, give city or town and state)
19
...... , to ...
19.
19.
death is said
Date of.
Underline the cause to which death should be charged sta- tistically.
17 Informant. (Address) 71 Paine St. Winthrop
5
6
ITI
FEB171940 AM
R-302
PewnegosisteM Wig & Ving Rove to the Clerk of the city of town in which the deceased resided as soon as possible
8 50m-10-'39. No. 8427-f after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) PARENTS
PLACE OF DEATH
(County)
Boston
(City or Town)
Beth Israel Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON (City or town making return) 2.20
Registered No.
793
(If death occurred in a hospital or institution, St. t give its NAME instead of street and number)
2 FULL NAME
Hyman Goldstein
(If deceased is a married, widowed or divorced woman, give also maiden name.)
54 Sea Foam Ave
......
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
Jan. 25,1940
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY.
1-10-40
19
That I attended deceased from
I last saw h
imalive on
1-25-40
.. ,
to.
1-25-40
19
19
., death is said
to have occurred on the date stated above, at.
11:10A
.m.
6 Age of husband or wife if alive.
years
7 IF STILLBORN, enter that fact here.
54
AGE
53
Years
Months.
Days
If less than I day
Hours
Minutes
Usual
9 Occupation:
Broken
Industry
10 or Business:
Insurance
1I Social Security No.
Boston Mass
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
Samuel Goldstein
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Ida Goldstein O.K
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17
Informant
(Address)
M Goldstein RBrother
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED 19
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
David Vicur Choulim-
DATE OF BURIAL
Jan ..... 26. 1940
19
22 NAME OF
FUNERAL DIRECTOR
B F Solomon
ADDRESS
Brookline Mass
Received and filed.
Jan .... 27 1940
19
(Registrar of City or Town where deceased resided)
PHYSICIAN
Major findings: mesentery
Underline
Of operations Carcinoma .. of .... recto.sigmoito cause to
and mesentari nodes
.. Date of.123-40
which death
should be
charged sta-
tistically.
Of autopsy ..
What test confirmed diagnosis ?.
20 Was disease or Injury In any way related to occupation of deceased ?
If so, specify
D Kopans
(Signed)
(Addres
Beth Israel Hospt
Date
1-25 - M.
40
19
Other conditions ...
Carcinoma of recto sigmo!
(Include pregnancy within 3 months of death)
with .. metastases .... to .... liver ... and
Daration
Immediate cause of death
Overwhelming infection
2 Days
Due to
B.Welchii
Due to
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 full)
(or) WIFE of
(Husband's name in full)
Dora Lebovich
(II U. S.
War Veteran,
specify WAR)
(a) Residence. No ..
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
St.
WinthropMass
(If nonresident, give city or town and state)
years
No.
Suffolk
1
(Cemetery)
(City or Town)
4
1
....
-
.
WITH
6
FEB171300 44
Suffolkx
PLACE OF DEATH
(County) Bouton
(City or Town)
No. Mass General 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.
893
S (If death occurred in a hospital or institution, St. 1
give its NAME instead of street and number)
2 FULL NAME
Richard Dana Carpenter
(If deceased is a married, widowed or divorced woman, give also maiden name.)
271 Winthrop
.St.
Winthrop
(If nonresident, give city or town and state)
months
2
days.
In this community 35'rs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX Male
4 COLOR OR RACE 5 SINGLE
MARRIED
White
WIDOWED
or DIVORCED
(write the word)
Married
18 DATE OF
DEATH.
Jan. 26,1940
(Month)
(Day)
(Year)
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
58
.years
7 IF STILLBORN, enter that fact here.
AGE.
8 60 Years 4 Months .:
12
Days
If less than 1 day Hours Minutes
Usual
9 Occupation:
Printer(Retired)
Industry
10 or Business:
Printing Business
11 Social Security No.
12 BIRTHPLACE (City)
South Boston Mass
(State or country)
13 NAME OF
FATHER
Jerome B Carpenter
14 BIRTHPLACE OF
FATHER (City)
(State or country)
-- Maine
15 MAIDEN NAME
OF MOTHER
Lesina ---
16 BIRTHPLACE OF
MOTHER (City)
.....
-- Maine
(State or country)
17
Informant
(Address)
Wife
(
Relation, if any
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Of autopsy
What test confirmed diagnosis ?
28 Was disease or Injury In any way related to occupation of deceased ?
If so, specify.
l"J"Rhees
(Signed)
M. D.
(Address)
Mass General Hospt Date 1-
.. 19 ....
40
21 PLACE OF BURIAL.
CREMATION OR REMOVAL ..... Forest Dale Malden Mass
(Cemetery)
(City or Town)
19
DATE OF BURIAL
Jan. 29.1940
22 NAME OF
FUNERAL DIRECTOR
A N Ward & Son
ADDRESS
Malden Mass
Received and filed
Jan. 31.1940
19
(Registrar of City or Town where deceased resided)
V
R-302
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 weeknd Wmich occurred in your city of town in case the deceased resided in another city or town at the time
50m-10-'39. No. 8427-f
PARENTS
Due to
Due to
to have occurred on the date stated above, at.1.Q .: 08P Immediate cause of death Hypertensive heart disease
.m.
Duration
6 Age of husband or wife if alive.
Lottie M Newton
19 I HEREBY CERTIFY,
Jan.
.26
14.0
to
Jan. 26
19 ... 40
That I attended deceased from
I last saw h .... m ... alive on.
Jan.
26
1940
death is said
years
.......
.....
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
1
Underline the cause to which death should be charged sta- tistically.
Date of.
2 Yrs
...
P
FEB17104001
IR-302
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. I .. ) 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
50m-10-'39. No. 8427-f
PLACE OF DEATH
Essex
(County)
Danvers (City or Town) Danvers State Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Denvers
(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 Christine Patterson
(If deceased is a married, widowed or divorced woman, give aiso maiden name.)
44 ..... illow ... Ave ..
...........
.St.
month6
days'3
In this community
yTs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
white
Or DIVORCED
(write the word)
married
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE ot
William Patterson
(Husband's name in full)
6 Age of husband or wife if allve .... cannotbe ..... learnedars 7 IF STILLBORN, enter that fact here.
8
AGE
6.4ears
Months ..
Days
If less than I day
Hours
Minutes
Usual
9 Occupation:
housewife
Industry IO or Business:
II Social Security No.
cannot be learned
12 BIRTHPLACE (City)
(State or country)
Nova Scotia
13 NAME OF
Willie: P.Grant
FATHER
14 BIRTHPLACE OF
Nova scotia
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Christina Gray
15 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova cotia
17
Informant.
(Address)
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred) 2/5/40
DATE FILED 19
18 DATE OF
Jan. 26, 1940H
DEATH
(Month)
(Day)
(Year)
IS I HEREBY CERTIFY,9 That htendes Cleteased from
, 19.
19.
I last saw h ....
... alive on ..
to have occurred on the date stated above, at ...... ................. Duration
ImBelliate mutecof deathrounds tis
Due to
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Date of.
clin ..
Underline
the cause to
which death
should be
charged sts-
tistically.
Of autopsy
What test confirmed diagnosis ?
no
20 Was disease or iojury in any way related to occupation of deceased ?
If so, specify .... detvin Goodman
(Signed)
(Address)
Dato
2/2/ 40
21 PLACETOE BURKAELIN
CREMATION- UR REMOVAL
Winthrop
DATE OF BURIAL
(Cemetery)
1/26/40 ity or Town)
22 NAME OF
FUNERAL DIRECTOR
Boston
ADDRESS
Received and filed
19
(Registrar cf City or Town where deceased resided)
1
No
(II U. S.
War Veteran,
specify WAR)
(2) Residence. No ..
(Usual place of abode)
Length of stay : In hospital or institution.
(Specify whether)
years
(If nonresident, give city or town and state)
25.10()52., death is said
...
PARENTS
Mary
Morhillkafn, if any
al researchas
501
IVINT
IP MASS
FEB131940 AM
A R-301 A;
1
PLACE OF DEATH
Suffolk (County) Winthrop (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.
Registered No ..........
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(If deceased is | married, widowed or divorced woman, give also maiden name.) 35-More
....... .........
.St.
Winthrop Muss
(If nonresident, give city or town and state)
Length of stay: In hospital or institution ..
years
months
days.
In this community
byrs.
mos.
days.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
(write the, word)
MARRIED
WIDO WED
Mamed
or DIVORCED
5a Ii married, widowe HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
G Age of husband or wife if alive.
54
.Years
7 IF STILLBORN, onter that fact here.
8
AGE 58 Years Months. Days Hours Minutes
Usual
9 Occupation:
Pr
10 or Business:
Industry
Boston american Hempel
11 Social Security No .......
023-03-5094
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
JaRae Savel
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Rena- Cannot be.
16 BIRTHPLACE OF MOTHER (City) (State or country)
17 Informant (Address) 35- Une
1 HEREBY CERTIFY that a satisfactory standard certificate of death was filed with cto BEFORE the burial or transit permit was issued: Nm. D. Children (Signature of Arenyod Board of Health ofother) Health affiche (Official Designation) (Date of Issue of Permiitt 2/3/40
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
Navog: 1 February-1-1940
(Month)
(Day)
(Year)
19
LHEREBY CERTIFY.
That ! attended deceased from
JUNE. 25,
19.39, to January 36, 1940 I last saw b.IM alive on JAN vary, 19.HA, death is said to have occurred on the date stated above, at. S .- 45. G.m. Immediate cause of death Cerebral Thrombosis
Duration IPIPORTANT 2.wks-
5 ielos.
6 /2 MOS
PHYSICIAN
Major findings :
Of operations
GENEral CarcinoMatosis
.Date of ...
Of autopsy
-
What test confirmed diagnosis ?.
20 Was disease or injury in any way related to occupation of deceased?
If so, specify ...............
/04
(Signed) Edward X' Hanger (Address) 200 Warth With with DeFeb.2 1940 verent
21
.... (City or Town)
Place of Burial, Cremation or Reagoval. ููู DATE OF BURIAL. 19. 40
22 NAME OF
FUNERAL DIRECTOR
Manuel Stantilly
ADDRESS
10-Wash. SX.W
Received and filed.
19
(Registrar)
information should be carefully supplied.
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.
100m-10-'39. No. 8427-e
Saral Sauel
Relation, if any
St. 1
2 FULL NAME
No 35- W to.
Savel
(If U. S. War Veteran, specify WAR)
(a) Residence. No .. (Usual place of abode)
white
Of divorced
Sedar
If less than 1 day
Due to
Migrating Thrombo Probiti's
Due to - Following Accident to lower.
Other conditions
back
GENEral CarcinoMatos15
(Include pregnancy within 3 months of death)
Underline the cause to which death should be charged sta- tistically.
, M. D.
PARENTS
AGE should be stated EXACTLY. PHYSICIANS should state
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 helief 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 hy the physician or officer and the date of his death ... Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a human hody 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 tomh other than the receiving tomb 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 huried. No such permit shall he issued until there shall have heen de- livered to such board, 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 accompanied, in case of an original interment, by a satisfactory certificate of the attending physician, if any, as required hy 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 hy 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 madc 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 he 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 hody has been sooner ohtained 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 issuc such permits, or if there is no such board. from the clerk of the town where the hody is to he huried or the funeral is to be held, or from a person appointed to have the care of the cemetery or hurial ground in which the interment is made .... Chap. 114, Sec. 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) 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 diseasc unrelated to any form of injury.
(2) Board of Heaith 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 supposabiy due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septice- mia), and hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, hut also deaths from disease resulting from injury on infection related to occupa- tion, the sudden deaths 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 Ocenpation .- 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 hy the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
1 R-301 A|
I
Winthrop
(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. 24
Registered No. (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Ralph Sherman Johnson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
22 Upland Road
St.
(If nonresident, give city or town and state)
years
months
days.
In this community 32 yrs.
mos.
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
(Month)
(Day)
(Year)
That I attended deceased from
5a If married, widowed, or dig drie Dimock 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
74 Years
8
Months
26
Days
If less than 1 day
AGE
Hours.
Minutes
Usual
Manufacturing dept (retired)
9 Occupation:
Industry
10 or Business:
U. S. Rubber Co
Due to
Other conditions
arquia Pectoris
2 years
12 BIRTHPLACE (City)
Framingham
(State or country)
Massachuse
13 NAME OF
FATHER
John Johnson
Major findings :
Of operations
none
14 BIRTHPLACE OF
Unable to obtain
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Mary Thompson
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Unable to obtain
I7 Relation, if any Informant Barbara Johnson daughter (Address)22 Upland Rd. winthrop
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