USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1941 > Part 45
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No undertaker or other person shall bury a buman body or the ashes thereof which have been brought into the cominonwealth until he bas received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made. . . . Chap. 114, Sec. 46, G. L., (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 bedside 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 by recognized disease unrelated 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 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 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 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 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 business, 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 bousework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
ORM R-302
PLACE OF DEATH
NORFOLK (County)
BROOKLINE
(City or Town)
No. 1691 ... BEACON
The Commontucalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BROOKLINE
134
(City or town making return)
S (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.)
(a) Residence. No.
34 TRIDENT AVENUE
St.
WINTHROP, MASS.
(Usual place of abode)
NURSING HOME
1
months
days.
In this community
yTs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
Frank Ruiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if alive 7.2
years
7 IF STILLBORN, enter that fact here.
8 AGE .... 6Q Years. Months. .Days
If less than 1 day
Hours.
. Minutes
Usual
9 Occupation :
Housewife
Industry
10 or Business :
Own home
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF FATHER Abraham Bosick
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
(Unknown )
16 BIRTHPLACE OF
MDTHER (City)
(State or country)
Russia
17 Frank Ruskin
Hay Bahany
Informant .. (Address) 34 Trident Avenue, Winthrop
A TRUE COPY
arthur
Shimmer
ATTEST:
(Registrar of ofty or town where death occurred)
DATE FILED
July .... 31,
19
41
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
July 30
1941
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
July 26
to
19.41
July 30
19
That I attended deceased from
I last saw h.er.
.. alive on
July ... 30
19 ... 41
death Is sald to
have occurred on the date stated above, at
7
P
m
Duration
Immediate cause of death Cancer of uterus
9
mos .
Due to.
Due to
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings : Of operations
Date of.
Underline the cause to which death should be charged sta-
Of autopsy
What test confirmed diagnosis ?.
Biopsy
20 Was disease or injury in any way related to oooupation of deceased ?
If so, specify
(Signed)
N ..... N ...... Levins
(Address)
30 Chambers St. Boston, 7/31 ,41
D.
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
Tifereth Israel, Everett
(Cemetery)
(City or Town)
19.
DATE OF BURIAL
July 31
41
22 NAME DF
FUNERAL DIRECTOR
Benjamin F. Solomon
ADDRESS
Brookline
Received and filed ?) .. 19.
(Registrar of City or Town where deceased resided)
1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.) resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
50m (e)-1-41-4667
1
Registered No.
380
MINNIE RUSKIN
(If U. S. War Veteran, specify WAR)
Length of stay: In hospital or Institution.
(Before death)
(Specify whether)
years
(If nonresident, give city or town and State)
41
tistically.
....
1
PLACE OF DEATH
(County) SUFFOLEI BOGity or Town) No Peter Bent Brigham Hospital WillardE
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
DOSTON
(City or town making return)
Registered No.
6380
§ (If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.) Ingalls
230 .... Pleasant
.
.. St.
Winthrop ... Mass
years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
July 13 1941
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY.
7/13/47
19.
.,
to 7/23/41
19
That I attended deceased from
I last saw h ... im alive on 7/13/41 19 death is said to have occurred on the date stated above, at ... 10/.55R. Immediate cause of death Duration .dy.s .... staphlococcus .... septicemia
Due to
multiple
Due to
Other conditions broncho .... pneumonia (Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Of autopsy
What test confirmed diagnosis ?
20 Was disease or Injury Is any way related to occupation of deceased ?
If so, specify. (Signed) H Benjamin
(Address)
Boston
Date
7/14/1947
CREMATION OR REMOVAL ..
Pine Grove Lynn
(Cemetery) (City or Town)
DATE OF BURIAL
July 16 1941 19.
22 NAME OF
FUNERAL DIRECTOR
C R Bennison
ADDRESS
Winthrop
Received and Hled .............
19
(Registrar of City or Town (where deceased resided)
+
2 FULL NAME
(a) Residence. No ..
(Usual place of abode)
Length of stay: In hospital or institution
3 SEX
male
4 COLOR OR RACE 5 SINGLE
MARRIED
white
or DIVORCED
WIDOWED
(or) WIFE of
6 Age of husband or wife if alive.
55
7 IF STILLBORN, enter that fact here.
9
AGE 53
Years
.. Months.
Days
Usual
clerk
9 Occupation:
Industry
10 or Business:
Il Social Security No.
032-012-084
12 BIRTHPLACE (City)
(State or country)
Lynn Mass
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
16 BIRTHPLACE OF
PARENTS
MOTHER (City)
(State or country)
17
Informant.
(Address)
50m-10-'39. No. 8427-f
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
of death should be transmitted on Forin R-302 to the clerk of the city or town in which the deceased resided as soon as possible
(State or country)
Lynn Mass
(write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(Give margaret M Kerrigan
(Husband's name in full)
years
li less than 1 day
.. Hours
Minutes
W P A Project
Edwin W Ingalls
15 MAIDEN NAME
OF MOTHER
Elmina Dobbins
Scotland
Martha A Ingalls-
A TRUE COPY.
ATTEST:
francis
(Registrar of city or town where death occurred)
DATE FILED
7/16/41
19
21 PLACE OF BURIAL, Relation, if any dau
Date of.
Underline the cause to which death should be charged sta- tistically.
V
M R-302
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
-
(Specify whether)
(If U. S. War Veteran, specify WAR)
(If nonresident, give city or town and state)
M. D.
١
١١٠ ١١
-
AUG13661 A
IM R-302
2 FULL NAME 3 SEX fem (or) WIFE of Usual 9 Occupation: Industry 10 or Business: 11 Social Security No. 12 BIRTHPLACE (City) (State or country) 16 BIRTHPLACE OF PARENTS MOTHER (City) (State or country) 17 Informant (Address) 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 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 (State or country)
PLACE OF DEATH
(County)
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
.136
(City or town making return)
Registered No
6624
(If death occurred in a hospital or institution, St. t give its NAME instead of street and number)
(a) Residence. No ....
(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
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
July 23 1941
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY.
6/25/41
19.
...... , to .....
That I attended deceased from
7/23/41
... ,
19 .....
I last saw h .......... alive on ....
7/22/41
... ,
to have occurred on the date stated above, at. 7/55A Immediate cause of death. broncho .... pneumonia
.. m.
Duration
1 .... d.y ...
gen arterio sclerosis
Due to
Due to
Other conditions .. senilepsychosis
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings : Of operations
Of autopsy
What test confirmed diagnosis ?.
20 Was disease or lajury in any way related to occupatiun of deceased ? If so, specify
(Signed)
M R Simpson
Boston
Date/23/
M. D.
........
Exeter Mass
DATE OF BURIAL
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
(Cemetery)
July 25 1941
19
(City cr Town)
22 NAME OF
FUNERAL DIRECTOR
C R Bennison
ADDRESS
Winthrop
Received and filed
19
(Registrar of City or Town where deceased resided)
I
No.
Boston .... State ... Hospital
..............
Collyer
(If U. S. War Veteran,
specify WAR)
45 Winthrop Shore Drive St.
.Winthrop ... Mas.s
(If nonresident, give city or town and state)
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)
(Husband's name in full)
6 Age of husband or wife if alive.
.years
7 IF STILLBORN, enter that fact here.
8 AGE. ... 7.9 .... Years Months. Days
If less than 1 day
Hours ....
.Minutes
at home
St.John N B
13 NAME OF
FATHER
Emmanuel Collyer
14 BIRTHPLACE OF
FATHER (City)
England .........
15 MAIDEN NAME
OF MOTHER
Mary J Crocker
Newfoundland
Mary T Collyer
Relation, if any sister
A TRUE COPY.
ATTEST:
8. Tay
(Registrar of city or town where death occurredh
DATE FILED
7/25/41
19
unk
Underline the cause to which death should be charged sta- tistically.
(Address)
.Date of.
19. death is said
Ellen
(If deceased is a married, widowed or divorced woman, give also maiden name.)
1
.. LA
M R-302
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 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
1
PLACE OF DEATH
St(County) BOSTONJ
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON137
(City or town making return)
Registered No.
6840
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
ShirleyF
Brooks
(If deceased is a married, widowed or divorced woman, give also maiden name.)
39 Johnson Ave
St.
Winthrop
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
....
years
months
days.
(If nonresident, give city or town and state)
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
(write the word)
white
or DIVORCED
divorced
5a If married, widowed, or divorced
HUSBAND of
.Huth ......
(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
AGE .... E.F .... Years ... ] ... ] ...
.. Months ... 2g.Days
If less than 1 day Hours .Minutes
Usual 9 Occupation:
retired
Industry
10 or Business:
Leather & Hides
11 Social Security No ......
011-01- 3888
12 BIRTHPLACE (City)
Winthrop ... Ma.6g
......
(State or country)
13 NAME OF
FATHER
Eugene D Brooks
14 BIRTHPLACE OF
FATHER (City)
(State or country)
PARENTS
15 MAIDEN NAME
OF MOTHER
Sarah Whitney
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Heniker NH
17 Sarah M Brooks
Informant
(Address)
Relation, if any đau
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred) 8/2/41
DATE FILED 19
18 DATE OF
DEATH
July 30 1941
(Month)
(Year) (Day) That I attended deceased from
19 | HEREBY CERTIFY.
7/27/41
19
7/30/41
, 19 ......
... , to ..
I last saw h.e.r ..... alive on
7/30/41
19.
death is said
to have occurred on the date stated above, at ... $/.05P.m. Immediate cause of death coronary ..... thrombosis
1 yr
.myocardialinfarction
Dueto _.... @cute .... ventricular .... failure .... das
V
Due to .. recent .... occlusion ... ofmerebral
artery pulmonary infarction -hrs
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 of deceased ?
If so, specify
(Signed)
WB Osgood
, M. D.
(Address)
Boston
Date7/31/1941
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Mt.AuburnCamb
DATE OF BURIAL
(Cemet
Aug 2 1949ty or Town)
22 NAME OF
FUNERAL DIRECTOR
C R Bennison
ADDRESS
Lexington Mass
19
(Registrar of City or Town where deceased resided)
1
I
No .. PeterBent .... Brigham ... Hospital
St. 1
(If U. S.
War Veteran,
specify WAR)
In this community
yrs.
mos.
days.
..... Looke.
(Give maiden name of whe in full)
5.8.
Duration
Underline the cause to which death should be charged sta- tistically.
Templeton Mass
19
Received and filed.
م
M R-305
uffoulx
(County)
Boston (City or Town)
Che Commonwealth of anlassathuseiis OFFICE OF THE SECRETARY (City or town making return). COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH Registered No ... 6819
(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME
George .... A
Leichton
(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.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE 5 SINGLE
MARRIED
white
WIDOWED
or DIVORCED
(write the word)
widowed
5a Ii marriod, widowed, or divorced
HUSBAND of
Alice J McCarthy
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
8 76 Years.
.10
.Months.
Days
If less than 1 day Hours Minutes
Usual 9 Occupation:
retired
Industry
10 or Business:
roofing business
11 Social Security No ..
12 BIRTHPLACE (City)
- Maine
(State or country)
13 NAME OF
FATHER
Luther Leighton
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Caroline Kelly
16 BIRTHPLACE OF MOTHER (City) (State or country)
17 Ronald Leighton
Informant
Relation, if any
son ....
.)
(Address)
A TRUE COPY.
ATTEST:
(Registrar of city of town where, death occurred)
DATE FILED
8/1/41
19
MEDICAL CERTIFICATE OF DEATH
13 DATE OF
DEATH
July 30 1941
(Month)
(Day)
(Year)
19 | 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.) Chronic cardio vascular disease .. prostatic hypertrophy
20 Accident, suicide, or homicide (specify).
Date of occurrence.
19
Where did Injury occur?
(City or town and State)
Did injury occur in or about the home, on farm, in industrial place, or in public place?
(Specify type of place)
Manner of
Injury
Nature of
Injury ...
While at work ?
Was there an autopsy ?
21 Was discase or injury lo any way related to occupation uf deceased ?
Ii so, specify
(Signed)
W H Watters.
Boston
Date
7/ 31 % 49
,M. D.
22 ..
winthrop
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
Aug 1 1941
19
23 NAME OF
FUNERAL DIRECTOR
C R Bennison
Winthrop
ADDRESS
Recoived and filed 19
(Registrar of City or Town where deceased resided)
-------
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided as soon as possible Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
PLACE OF DEATH
No ...
Mass .... GeneralHospital
(If deceased is a married, widowed or divorced woman, give also maiden name.)
49 49 Beacon
St. Winthrop
(If nonresident, give city or town and state)
years
AGE
25m-10-'39. No. 8427-g
PARENTS
Maine
- Me
(Address)
Winthrop Mass
M R-302
3 SEX
male
HUSBAND of
(or) WIFE of
8
AGE
6 Years
9 Occupation:
Industry
10 or Business:
12 BIRTHPLACE (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Informant
(Address)
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
(State or country)
4 COLOR OR RACE 5 SINGLE
white
MARRIED
WIDOWED
or DIVORCED
(write the word)
married
5a If married, widowed, or divorcedazel
(Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if aljannot be learned years 7 IF STILLBORN, enter that fact here.
If less than 1 day
Hours ..
Minutes
Usual
Typewriter repair man
1I Social Security No.
cannot be learned
Somerville
13 NAME OF
FATHER
Louis Bates
14 BIRTHPLACE OF
FATHER (City)
Cannot be learned
Ruth Bailey
Cohassett
17 M.K.McPhillips
Relation, if any
DISH
A TRUE COPY. /
ATTEST:
(Registrar of city or town where death occurred) 8/2/41
DATE FILED 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
July 31, 1941
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY.
Jan
17
19 .. 4.1
to.
July
3.1 ...... 19 .. 4.1
That I attended deceased frore
I last saw h.h ......... alive on.
.....
JULIV
3.3 18 .... 4] death is said
to have occurred on the date stated above, at .............. 5/m. Immediate cause of death. Generalized arteriosclerosis
2 yrs Arteriosclerotic heart disease 2yrs
Due To
Bronchopneumonia
1 week
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 ?.
should be charged sta- tistically.
20 Was disease or Injury la any way related to occupation of deceased ? Cin ical If so, specify.
(Signed)
Abraham Gardner
DSH
M. D.
(Address)
Woodlawn
Nabhua N.H.
DATE OF BURIAL
22 NAME OF
FUNERAL DIRECTOR
Charles H. Farwell
ADDRESS
Nashua, I.H.
19
Received and flod.
(Registrar of City or Town where deceased resided)
-
-
26 Pico Avenue
.....
St.
Winthrop
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution ..
...
years
6
months
14days.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
50m-10-'39. No. 2427-f 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 PARENTS
PLACE OF DEATH
Essex
(County) Danvers
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
(City or town making return)
139
Registered No.
(If death occurred in a hospital or institution,
No Danvers State Hospital
St.
give its NAME instead of street and number)
2 FULL NAME
Henry J. Bates
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(If U. S.
War Veteran,
specify WAR)
(If nonresident, give city or town and state)
In this community
yrs.
mos.
days.
₹
Date
83/1 /87
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
(Cemetery)
8/ 2(City ]or Town)
.19.
Date of
Duration
Monthe.
Days
M R-301 A
r PLACE OF DEATH
7 Suffolk (County)
1 Winthrop (City or Town) No. 20.HaunBar Avenue
The Commonmoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filled for burlal permit with Board of Health or Its Agent. 140
Registered No.
X& & ( If death occurred In a hospital or Institution, {give its NAME instead of street and number) -
2 FULL NAME
Matthew James Owens
(If deeeased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
20 Faun Bar Avenue
St.
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution.
( Before death)
( Specify whether)
years
months
days.
In this community
3 0yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
august
2
1941
(Month )
(Day)
(Year)
July 28
19 ........
to.
1941
last saw h ........ .... allve on
Cuz
- . 194/ death is said to
have occurred on the date stated above, at
Immediate cause of death
Coronary Thrombosis
IMPORTANT
3no5.
Due to
Car
Celerona 2 jana
Due to.
Other conditions.
(Include pregnancy within 3 months of death)
IMPORTANT
Major findings :
Of operations ..
Of autopsy
What test confirmed dlagnosis ?.
Clinical Signs
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 ? 20 If so, specify.
('Signed)
(Address)
..... , M. D.
Date Cao
3 1941
a Tewksbury Cemetery Tewksbury Mass
Place of Burial, Cremation or Removal.
DATE OF BURIAL
August 4,
City or Town)
19
22 NAME OF
FUNERAL DIRECTOR
Charles R. Bennison
ADDRESS Winthrop Mass
Received and filed.
19
(Registrar)
100m (d) -1-41-4667
(Usual place of abode)
3 SEX
Male
4 COLOR OR RACE
White
(or) WIFE of
7 IF STILLBORN. enter that fact here.
8
AGE
.7.3. Years
9
... Months ...
16 ... Days
11 Social Security No ..
12 BIRTHPLACE (City)
Halifax
13 NAME OF
FATHER
Matthew Owens
14 BIRTHPLACE OF
FATHER (City)
St. John
15 MAIDEN NAME
PARENTS
MOTHER (City)
Informant4.
if deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
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.
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH In plain
(State or country)
Nova Scotia
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
Sa If married, widowed, of divored anche Richardson HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
73
6 Age of husband or wife if alive years
If less than 1 day
Hours
Minutes
Usual
Occupati
Advertising novelty business
Industry
10 or Business :
Selfemployed as above
(State or country)
Newfoundland
OF MOTHER
Ellen Cavanaugh
16 BIRTHPLACE OF
St. Johns
(State or country)
New Brunswick
17 Mrs. Laura B. Owens 1 Relation, if any (Address) 20 Haun Bar Ave. Winthrop Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was Issued: Www. D. Children ...
(Signature of Agent of Board of Health or other) Health Officer 8/4/41
(Official Designation) (Date of Issue of/Permity
HEREBY CERTIFY,
That I attended deceased from
10:30 am
Duration
Date of
PHYSICIAN - IMPORTANT
(Was deceased a
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