USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1940 > Part 70
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years
A VIII ALJUS LU LAIT LICIA UI LIIC LILY
PARENTS
Maine
Lewiston
(Signed)
St.
6
JAN-91941 CY
MR-301 A
PLACE OF DEATH
Suffolk (County)
7
'inthrop
(City or Town)
No. 59 Quincy Ave.
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. : 234
Registered No.
§ (If death occurred in a hospital or institution, ¿ give its NAME instead of street and number)
2 FULL NAME
Cleora Green
(If deceased is a married, widowed or divorced woman, give also maiden name.)
59 Quincy Ave.
St.
(If nonresident, give city or town and state)
Length of stay: In hospital or institution.
(Specify whether)
years
months
days.
In this community 3 yrs. 7
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
singl
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 STILLFORN. enter that fact here.
8
3
AGE
Years
7
Months.
.. Days
.Hours.
Minutes
Usual
9 Occupation :
Industry 10 or Business :..
11 Social Security No ....
12 BIRTHPLACE (City).
(State or country)
Massachusetts
13 NAME OF
FATHER
Oliver Green
14 BIRTHPLACE OF
FATHER (City) ...
Winthrop
(State or country)
Massachusetts
15 MAIDEN NAME
OF MOTHER
Cleora M. Perry
16 BIRTHPLACE OF
MOTHER (City).
Boston
(State or country)
Massachusetts
17
F .
Relation, if any
Informant.
Oliver Green
(father ..
V
(Address)
59 Quincy Ave
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the buriel or transit permit was issued: Www. D. Children .... (Signature of Agent of Board of Healthfor other) Health afferr 1/2/4/
(Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
December
31
1940
(Month)
(Day)
1
(Year)
19 I HEREBY CERTIFY. That I attended deceased from
m. Dec. 10 19.40, to alex. 31 19 40 I last saw her alive on December 24, 1940, death is said to have occurred on the date stated above, at. V:15 6
Duration IMPORTANT
.... 2 danço
Due to.
P. f
Pertussis
4 works
Due to
Other conditions.
(Include pregnancy within 3 months of death)
IMPORTANT PHYSICIAN
Underline the cause to which death should be charged sta- tistically.
20 Was disease or injury in any way related to occupation of deceased ?. NO
If so, specify arthur @norran
(Signed).
ess) Winthrop mars Date San 1
19.41.
M. D.
21 ..
Cambridge
Cambridge
Place of Burial, Cremation or Removal.
January 2.
(City or Town)
41
DATE OF BURIAL ...
19
22 NAME OF
FUNERAL DIRECTOR ..
John f. Omaley
ADDRESS
Winthrop, Massachusetts
Received and filed. 19
(Registrar)
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
100m-2-'40-D-729-a
is very important. See instructions and extracts from the laws on back of certificate.
PARENTS
Major findings:
Of operations.
-
Date of
Of autopsy.
What test confirmed diagnosis ?. clinical
Immediate cause of death Probable bronchopneumonia
If less than 1 day
Cambridge
St.
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No ......
(Usual place of abode)
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 registration a standard certificate of death, stating to the hest 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 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 buman hody in a town, or remove therefrom a human hody which has not heen huried, until he has received a permit from the hoard of health, or its agent appointed to issue such permits, or if there is no such hoard, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human hody and remove it from a town, from one cemetery to another, or from one grave or tomh other than the receiv- ing 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 buried. No such permit shall he issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required hy law to be returned and recorded. which shall be accompanied, in case of an original interment, hy 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 he obtained early enough for the purpose. or is in- sufficient, a physician who is a member of the board of health, or em- ployed by it or hy the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused hy violence, the medical examiner shall make sucb certificate. If such a permit for the removal of a human hody, not previously interred, from one town to another within the commonwealth cannot he 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 hody 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 re- moval of such hody has heen sooner ohtained bereunder. If the death certificate contains a recital, as required by section ten of chapter forty- six. tbat the deceased served in the army, navy or marine corps of the United States in any war in which it has heen engaged, such recital shall appear upon the permit. The hoard 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 furnish for registration any other necessary information which can he obtained as to the deceased, or as to the manner or cause of the deatb, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a buman body or the asbes thereof which bave been hrought into the commonwealth until he has received a permit so to do from the hoard of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town wbere 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 burlal ground in wbicb 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 observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given hedside care during a last illness 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 unrelated to any form of injury, have died without recent medical attendance or whose physician is ahsent from bome when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposahly due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), 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 occupation, the sudden deaths of persons not disahled 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 deatb. As related causes, name earlier morbid conditions, 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 bealthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupation had heen given up or changed on account of the disease causing death, report the usual occupation prior to illness. If the deceased had retired from husiness, 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 bad no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
R-305
No ... 3 SEX Male HUSBAND of (or) WIFE of AGE Usual 9 Occupation: Industry 10 or Business: PARENTS 25m-10-'39. No. 8427-g 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 (State or country)
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
(write the word)
white
or DIVORCED
married
5a If married, widowed, or divorceHarriet I Cary (Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
8 81 Years 3 Months 3 Days
If less than I day Hours .. Minutes
physician
11 Social Security No.
12 BIRTHPLACE (City)
Upton Mass
13 NAME OF
FATHER
Patrick Delaney
14 BIRTHPLACE OF
FATHER (City)
Ireland
(State or country)
15 MAIDEN NAME OF MOTHER
16 BIRTHPLACE OF MOTHER (City) (State or country)
Ireland
17 Informant (Address)
wife
Relation, if any
A TRUE COPY
vance
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
12/4/40
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH .
Dec 1 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.) Broncho pneumonia. Multiple
fracture.
20 Accident, suicide, or homicide (specify).
accident
Date of occurrence.
12/25/40
Where did
Injury occur?
Roxbury Mass
(City or town and State)
Did injury occur in or about the home, on farm, in industrial place, or in
public place?
street
Manner of
Injury
hit by auto
Nature of Injury
While at work ?.... NO;
.Was there an autopsy ?
no
21 Was disease or injury in any way related to occupation of deceased ?
Il so, specify
(Signed)
C. J O'Leary
M. D.
(Address)
Boston
Date
12/36 40
22 ..
Forest Hills Crem
Boston
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
Dec 3 1940
19
23 NAME OF
FUNERAL DIRECTOR
J S Waterman & Sons
Boston
ADDRESS.
Received and filed 19
(Registrar of City or Town where deceased resided)
( BOSTON
(City or town making return)
Registered No ..
10256
(If death occurred in a hospital or institution, 1 St. ( give its NAME instead of street and number)
2 FULL NAME
Richard
Delaney
(If deceased is a married, widowed or divorced woman, give also maiden name.)
105 Grovers Ave
........
St.
(If U. S.
War Veteran,
specify WAR)
Winthrop Mass
235
(a) Residence. No ..
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
years
months
days.
(If nonresident, give city or town and state)
In this community
yrs.
mos.
days.
PLACE OF DEATH
SSUFFOLK (Countx) BOSTON
(City or Town)
Peter Bent Brigham Hosp
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
6.9
years
19
(Specify type of place)
Ú
JAN161941 MA
MR-302
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
50m-10-'39. No. 8427-f
1
PLACE OF DEATH
JOURBULK (County) 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
10364
(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
123 Hermon
.....
St.
Winthrop
(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 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)
6 Age of husband or wife if alive.
.years 7 IF STILLBORN, enter that fact here.
8 18
AGE Years. 9 Months 5 Days
If less than I day
Hours.
Minutes
Usual
9 Occupation:
at home
Industry 10 or Business:
1I Social Security No.
12 BIRTHPLACE (City)
(State or country)
Boston Mass
13 NAME OF
FATHER
James T Whooley
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston
15 MAIDEN NAME
OF MOTHER
Rose A McNulty
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston
17 John J Whooley
Relation, if any BY
Informant
(Address)
above
(
A TRUE COPY.
Avances
ATTEST:
1 4ans
(Registrar of city or town where death occurred)
DATE FILED
12/7/40
19
18 DATE OF
DEATH.
Dec 3 1940
(Month)
was a patient
19 1 H
1'0727/40
19.
.....
to.
19
...
Plast saw h .... Malive on
-12
19.
, death is said
to have occurred on the date stated above, at ..
5/50P
m.
Duration
Immediate cause of death.
rheumatic ... heart .... disease
mo
Due to
cardiac ... decompensationunk
Due to
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 ?.
20 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
W O' Connell
M. D.
(Address)
Boston
Date 12/4/1940
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
St Joseph's Boston
DATE OF BURIAL
(Cemetery)
Dec 6 1940
19
22 NAME OF
FUNERAL DIRECTOR
R C Kirby
ADDRESS
Bo.s.ton
Received and filed
19
(Registrar of City or Town where deceased resided)
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
No.
Boston City Hospital
William
Whooley
(If U. S.
War Veteran,
specify WAR)
236
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
CERTIFY.
That I attendech deceased from
PARENTS
Date of
should be charged sta- tistically.
(City or Town)
1
JANIGIOM MI
MR-302
1
PLACE OF DEATH
SUFFOLK 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. 10821 .......
(If death occurred in a hospital or institution, St. t give its NAME instead of street and number)
237
2 FULL. NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
140 Circuit Rd
St. .. Winthrop .... Masg.
(If nonresident, give city or town and state)
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
(write the word)
male
white
or DIVORCED 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.
AGE
Years
8
3
Months.
15 Days
If less than 1 day Hours Minutes
Usual 9 Occupation:
Industry 10 or Business:
1I Social Security No.
12 BIRTHPLACE (City)
(State or country)
Winthrop Mass
13 NAME OF
FATHER
John J Monahan
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston Mass
15 MAIDEN NAME
OF MOTHER
Frances E Murphy
18 BIRTHPLACE OF
MOTHER (City)
Boston-
(State or country)
17
Informant.
(Address)
father
Relation, if any
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
occurred
DATE FILED
12/21/40
19
21 PLACE OF BURIAL.
CREMATION OR REMOVAL
Winthrop
Masg
(Cemetery)
(City or Town)
DATE OF BURIAL
Dec 20 1940
19
22 NAME OF
FUNERAL DIRECTOR
R ... C ..... Kirby
ADDRESS
Boston.
Received and filed.
19
(Registrar of City or Town where deceased rexided)
...........
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Date of.
Of autopsy
What test confirmed diagnosis ?
20 Was disease or injury In any way related to occupation ol deceased ?
If so, specify.
B Alexander Jr
(Signed)
M. D.
(Address)
Boston
Data1.2/199 .4.0
50m-10-'39. No. 8427-f
of death should be transmitted on Form K-JUZ 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. L.)
No.
TheChildren's ... Hospital
.....
Monahan
(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
days.
In this community
yrs.
18 DATE OF
DEATH.
Dec .... 191940
(Month)
(Day)
That I attended deceased from
(Year)
19 I HEREBY CERTIFY.
9/28/40
19
12/19/40
.... , to.
.. , 19
...
I last saw h .. 1m ... alive on ..... 1.2, ... 1.9./!\Q .. , 19 ........ , death is said to have occurred on the date stated above, at 5/35Am. Duration Immediate cause of death. P.o.s.t .... operati.v.e ..... shock
Due to abscess of bile ducts
Due to
Underline the cause to which death should be charged sta- tistically.
PARENTS
John
P.
JAN1GISLI A1
DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH Maine
State File No. Registrar's No.
State of
1. PLACE OF DEATH.
(a) County
(b) City or town
Poland
(c) City or town Winthropell
Off outside city or town limit . write RURAL)
(d) Street No.
14 Perkins
(If rural, give location)
(If not in hospital or institution, write street number or location)
(d) Length of stay: In hospital or institution
In this community
3% hre.
years, months or day's)
3. (a) FULL NAME: Villian Cohent
MEDICAL CERTIFICATION
20, Date of death: Month Sefat day 16
year ___ 2_ 0 hour
minute
21. I hereby certify that I attended the deceased from 19 , tổ
19
4. Sex
race
20
divorced
6. (c) Age of husband or wife if
6. (b) Name of husband er wife Mollie Meinberg alive 50 years
7. Birth date of deceas defat.
516 1889 (Day) (Year)
8. AGE:
Years
Months
If less than one day
5/
hr. min
9. Birthplace
Quasia --
10. Usual occupation
11. Industry or busines vefat market
MOTHER FATHER
12. Name Melvin Cohen 13. Birthplace Queria (State or foreign country)
(City town, or county)
14. Maiden name Tene
15. Birthplace
(City, town. or county)
16. (a) Informant's own signature Mollie Cohen
22. If death was due to external causes, fill in the following:
(6) Date there de 67. 17, 19 40 (4) Accident, suicide, or homicide (specify) 17. (a) Burial
(Month) (Day) (Yeah)
(c) Place; burial or cremation Vinthesofa, mace (b) Date of occurrence
(c) Where did injury occur?
(City or town) (County) (Stato)
18. (a) Signature of funeral director,
(+) Did injury occur in or about home, on farm, in industrial place, in public place?
(Specify type of place)
While at work? (e) Means of injury
W. W. Isoleter (M. D. or other).
(Date received local registrar)
(Registrare signature)
Address Lewiston me. Date signed
8-6917
U. S. GOVERNMENT PRINTING OFFICE 16-13493
PHYSICIAN
(Inciude pregnancy within 3 months of death)
Major findings: Of operations
Of autopsy
Underline the cause to which death should be charged sta- tistically.
(b) Addresz (
(Burial, cramation, or removal)
(b) Address Poland me.
19. (a) 9/16/40 (b) C. C. Mitchell 23. Signature
2. USUAL RESIDENCE OF DECEASED: (a) Stat: hace (b) County
Suffolk
(If outside city or town limits, warto RURAL)
(c) Name of hospital or institution:
(Specify whether
If foreign born, how long in U. S. A .? years.
3. (b) If veteran,
name war
3. (c) Social Security No.
5. Color or
6. (a)Single, widowed, married,
that I last saw h _____ alive cn 19
and that death occurred on the date and hour stated above.
Duration
Immediato cause of death Cerebral hemorrhage
Due to
Due to
(Cin. tem. or county) (State or foreign country)
Other conditions ... Diabetes
quecia (Stata or foreign country)
-
(Monti
FEB 201941 101
R-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. L.)
50m-10-'39. No. 8427-f
PLACE OF DEATH
(County) Middleton
(City or Town) Eccoles Sanatoria
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
239 huddletor
(City or town making return)
Registered No.
(If death occurred in a hospital or institution, No. St. 1 give its NAME instead of street and number) William Itry it out
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
297 Picture
St.
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution ...
(Specify whether)
Itropical
years
1 months 3 days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
18 DATE OF
DEATH.
(Month)
4
1940
(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)
to have occurred on the date stated above, at .!
12 -10 A
Duration
6 Age of husband or wife if alive.
7 IF STILLBORN, enter that fact here.
AGE
8 53 Years 11 Months 9 Days
If less than I day
Hours.
Minutes
Usual
9 Occupation:
Blank Postoffice
Due to
Industry 10 or Business:
Il Social Security No ..
12 BIRTHPLACE (City)
(State or country)
--
13 NAME OF
FATHER
Jamie Start
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17
Pecado
(.
Relation, if any
Informant.
(Address)
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
Other conditions
2000
PHYSICIAN
(Include pregnancy within 3 months of death)
Major findings :
Of operations
none
Date of.
Of autopsy
none
X Ray
What test confirmed diagnosis ?.
Patin Status
20 Was disease or lujury In any way related to occupation of deceased ?
If so, specify.
Daa & Pettingett
(Signed)
huddleston
8/00
. M. D.
19.40
(Address)
Date.
malden
21 PLACE OF BURIAL.
CREMATION OR REMOVALZ ..
(Cemetery)
DATE OF BURIAL
22 NAME OF
FUNERAL DIRECTOR
Edwin a Same
ADDRESS
201 ourdrin 81 wok
Received and filed 19
(Registrar of City or Town where deceased resided)
4/2 que .....
Due to
19 I HEREBY CERTIFY.
That I attended, deceased from
1940
to.
19910
9 .. 2
....
I last saw h .....
.alive on
Cmq 3
.... 19.2 ..... , death is said
52
years
MEDICAL CERTIFICATE OF DEATH
Immediate cause of death
Pulmonary Tuberculosis
PARENTS
Underline the cause to which death should be charged sta- tistically.
(City of Town)
1944
1
(If U. S.
War Veteran,
specify WAR).
(If nonresident, give city or town and state)
1.00 AM
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