USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1942 > Part 53
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No undertaker or other person shall bury a human body or the ashes thereof which have heen 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 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 disahled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is ahsent from home when the certificate of death is necded.
(3) Medical Examiners will investigate and certify to all deaths supposahly due to injury. These include not only deaths caused directly or indirectly hy traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or elcctrical agents, and deaths following abortion, hut 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 he 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 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
ANTI The &
writer Set Tobe . V
V
Za, Month Day Year 2 Hour
DATE OF DEATH: 7 1942 3P
8. Bez - Male or Female ?
Male
White
Single
Nope
OK (State or Foreign Country) Unknown
12 Sosie! Security Number
No
14. City or Towa - (If outalle city or towa limite write RURAL)
16. Farish and Ward No.
Rural 1} Mi. East of Esler Field, La
Rapides Ward 20
1 Month
17. Name of Hospital or Institution (L/ not in hospital er lastitation give atrest ne. er location)
Rural 1. MH East of Esler Field La.
None
10. City or Town - (L' outside city or town lasits write RURAL)
20. Farish and Ward No. Unknown
21. State Massachusetts
19
209 Cliff Arome
No
EL Nume of Father
26. Birthplace of Father
24. Name of Mother
87. Birthplace of Mother Unknown
Charles T.Eillook 8s Unknown
MANT'S ICATION
I certify that the above stated Information is true and correct to the best of my knowledge.
imbur H. Wood Capt. A.C.
May 9, 1942
OF DEATH 73-4
Multiplen facturas of alle lang Camera 1
Duration
É owy Ommanione (Include pregnancy within three months of death)
How
18. Woor Findings of Operations So operation
34. Woor Findings of Autopay Ho oute pay.
16. Accident, But'da, or Homicide | 16. Date of Occurrence
(Speelty)
plane crash Max 7. 1912
Fast of Faler Field, La.
(Appelly type of pto)
Arplane crash
CIAN'S ICATION
OD. Robinson Ist. Br.mc
15. Pince of Burial or Cremation
1 40 Signature of Faserel Director
DIRECTORS ATION
Cremation 15/9/1942 Newton. Mass Remove!
Hixson Bros
NAL DATA CEASED
la. Last Name of Decenecd
Tillock Jr.
1. First Name
Charles
T.
Color or Race
Debossed | U woder 1 day | fa. Birthplace (City or town)
Date of Birth of Decessed 10,1919
8.
22
10. Joel Occupation
11. Industry or Business
tor
OF DEATH 1000
RESIDENCE CEASED
Winthrop
21. Street Address - (If rural give location)
28. 1% consel a citizen of a foreign country ? If yes, Dame country
TS
Darethe
37. Where did injury ocet? (City of town, perl') and, state)
IS DUE TO NAL NCE
le. Deceni Name
CERTIFICATE OF DEATH HT N .....
156
10. L . NON
OCT -61942 851
NON-RESIDENT OF Massachusetts
Dlc
RM R-301
RHODE ISLAND STATE DEPARTMENT OF HEALTH
157
City or Town No.
Division of Vital Statistics
1. PLACE OF DEATH
COPY OF RECORD OF DEATH
City or Town Westerly
St. and No.Margaret Edward Anderson Hosp. (If death occurred in a hospital or institution, give ita NAME instead of street and number)
Length of residence in city or town where death occurred .......... yra .. 2 .. mos ........... de. How long in U. S. if of foreign birth ?.. 23 yrs mos. ds
2. FULL NAME
Caroline Louise Sawyer
War Record.
(Name of War)
(a) Residence:
St. and No.
82 Loring Road
City or Town
Winthrop, Mass
(If nonresident give city or town and State)
(Usual place of abode)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3. SEX
4. COLOR OR RACE | 5. Single, Married, Widowed,
or Divorced (write the word)
White
Married
21. DATE OF DEATH.
August
3
19 42
22.
I HEREBY CERTIFY, That I attended deceased from
July 23
19 42, to August 3
19 42
I last saw h .......... alive on.
August 3
19.42; death is said
to have occurred on the date stated above at 0:40a. .m.
The principal cause of death and related causes of importance
were as follows:
# (See below)
7. AGE
Years
Months
10
Days
5
If LESS than
1
day ........ hrs.
or .......... min.
General peritonitis from
Date
of onset
8. Trade, profession, or particular
kind of work done, as spinner
sawyer, bookkeeper, etc.
Housewife
OCCUPATION
9. Industry or business in which
work was done, as silk mill,
saw mill, bank, etc ....
At Home
10. Date deceased last worked at
this occupation (month and
year) QUIV 1942
11. Total Time (years)
spent in this
occupation .....
Life
12. BIRTHPLACE (city or town)
Kingston
(State or country) Ontario
MOTHER | FATHER
13. NAME
Lewis Seymour Haddon
14. BIRTHPLACE (city or town)
Pickton
(State or country)
N. Y.
15. MAIDEN NAME (Full name)
Maud Louise Barrie
16. BIRTHPLACE (city or town).
Kingston
(State or country)
Ontario
17. INFORMANT .....
George A. Sawyer
(Address)
82 Loring Road, Winthrop
(Relation to deceased) .. Husband
Mass.
18. BURIAL
CREMATION
REMOVAL
or OTHERWISE
City or Town
Winthrop, Mass
Name of Cemetery
Winthrop
19. Signature of
Embalmer ...
E. T. Avery
481
(License No.)
Funeral
Avery Funeral Service
6
(License No.)
20. FILED Aug. 3, 1942 W. Russell Dower Local Registrar.
24. Was disease or injury in any way related to occupation of deceased?
,No.
If so, specify
(Signed)
J. Gordon Anderson, M.
.D.
(Degree)
(Address)
23 Cross St. Westerly R.I
* For more space use other side.
22,42
from peritonitis
July 25, '42
Other contributory causes of importance:
Name of operation # ...
none
Date of.
Was there an autopsy ?............. What tests confirmed diagnosis? t.C .... in ical
urine and blood chemistry analysis
23. If death was due to external causes (violence) fill in also the following:
Accident, suicide, or homicide !.
Date of injury.
19
Where did injury occur ?.
(Specify city or town, county, and State)
Specify whether injury occurred in industry, in home, or in public place.
Manner of infury.
Nature of injury.
4
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of is very important. See instructions and extracts from the laws on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
Female
(or) WIFE
George A. Sawyer
6. DATE OF BIRTH (month, day and year) Sept. 28, 1885
6a. If STILLBORN enter that fact here.
Months of
gestation ..
(month, day, and year)
5a. If married, widowed, or divorced (if wife, FULL MAIDEN name)
HUSBAND
56
ruptured appendix
July
Acute focal toxic nephritis
Director.
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 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 human body in a town, or remove therefrom a human body which has not been huried, 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 board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been 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 bc 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 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 physician who is a member of the board of health, or employed by 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 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 made as above provided and in the possession of the undertaker desiring to make such a 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 contains a recital, as required hy 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 heen 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 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 funcral 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 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 discase 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 septice- mia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, but also deaths from disease resulting from injury or 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 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 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 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
DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
State File No.
139
Registrar's No.
State of Rhode Island
1. PLACE OF DEATH:
(a) County
Washington
(a) State
(c) City or town
Winthrop,
(If outside oity or town limita, write RURAL)
(c) Name of hospital or institution:
Margaret Edward Anderson Hospital
Wall Street No.,82 Loring Road
(If not in hospital or institution, write street number or location)
(If rural, give location)
In this community
(Specify whether
If foreign born, how long in U. S. A .?
23
years.
3. (a) FULL NAME Caroline Louise Sawyer
20. Date of death: Month
August
day
hour
6
minute
40 A.M.
4. Sex
Female
race
White
divorced
Marr
that i last saw h_er_ alive on
August
3,
1942:
6. (b) Name of husband or wife
6. (c) Age of husband or wife # ff and that death occurred on he date and hour stated above.
years
Immediate cause of death .
7. Birth date of deceased
September
(Month)
(Day) (Year)
8. AGE:
Years
56
Months
10
Days
5
If less than one day --
Due to
in.
from peritonitis
9. Birthplace
Kingston, Ontario
(State or foreign country)
11. Industry or business
at home
12. Name
Lewis Seymour Haddon
13. Birthplace
Pickton,
New York
14. Maiden name
Muur Louise Barr'te or foreign country)
Major findings: Of operations
15. Birthplace
Kingston,
Ontario
(City. town, or county)
(State or foreign country)
Of autopsy
Underline the cause to which death should be charged sta- tistically.
16. (a) Informant's own signature George A. Sawyer (Husband)
(b) Address.
82 Loring Road, Winthrop, Mass.
22. If death was due to external causes, fill in the following:
(a) Accident, suicide, or homicide (specify)
(c) Place; burial or cremation
(b) Date of occurrence
Where did injury occur?
(City or town) (County)
(State)
18. (a) Signature of funeral director
(d) Did injury occur in or about home, on farm, in industrial place, in public place?
(Specify type of place)
19. (a) 8/3/42
(b) W .__ Russell Dower
23. Signature Gordon Anderson, M. D(M. D. or other)
(Date received local registrar) (Registrar's signature)
It Address 23 Cross St., Westerly, R. Date signed
8-6917
U. S. GOVERNMENT PRINTING OFFICE 16-13493
3.
3. (6) If veteran,
name war
3. (c) Social Security
No.
21.
hereby certify that I attended the deceased from
July
5. Color or
6. (a)Single, widowed, married,
23,
., to
19.42
August
3,
19.42
Duration
alive 28, 1885
General peritonitis from
7/22742
ruptured appendix.
Acute focal toxic nephritis
7/25/42
Due to
10. Usual occupation
Housentre
MOTHER FATHER
Other conditions
PHYSICIAN
(Include pregnancy within 3 months of death)
17. (a) __ Burial
(Burial, cremation, cr removal)
Winthrop Cemetery
(Year)
(b) Date thereof
Winthrop, Mass.
Avery Funeral Service
(b) Address
While at work? (e) Means of injury
(b) County
(b) City or town
Westerly,
(If outside city or town limite, write RURAL)
(d) Length of stay: In hospital or institution
2 months
years, montha or days)
MEDICAL CERTIFICATION
year
1942
hr.
2. USUAL RESIDENCE OF DECEASED:
Mass.
li
-
RM R-305
No. 3 SEX male (or) WIFE o !. 8 AGE. 79 Years Usual 9 Occupation: Industry 10 or Business: 13 NAME OF FATHER PARENTS 25m-10-'39. No. 8427-g 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 (State or country) 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
PLACE OF DEATH
SUFFOLK
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(City or town making return)
158
Registered No.
6552
(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.)
70 Atlantic
...........
St.
(If nonresident, give city or town and state)
years
months
days.
In this community
yrs.
mos.
days.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
white
or DIVORCED
widowed
5a If married, widowed, or divorced HUSBAND of
Elizabeth McLean
(Give maiden name of wife in
(Husband's name in full)
6 Age of husband or wife if alive.
7 IF STILLBORN, enter that fact here.
If less than 1 day
Hours
Minutes
boiler maker
Contractor
11 Social Security No.
Prince Edward IS
12 BIRTHPLACE (City)
Canada
Alexander MacCormack
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME OF MOTHER
-
16 BIRTHPLACE OF MOTHER (City) (State or country)
17 John MacCormack
Relation, if any ....... gon)
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
8/7/42
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATIL .. Aug 4 1942
(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.) fractured base of skull fractured cervical vertebra
20 Accident, suicide, or homicide (specify) .... accidental
Date of occurrence.
Aug 3 1942
19
Where did
Injury occu :?.
Winthrop
(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
Fell accidentally on stairs
Nature of
at Winthrop on Aug 3 1942
Injury
While at work?
Was there an autopsy ?...
.no
21 Was disease or lojary in any way related to occupatica of deceased ?.
If so, specify.
(Signod)
W J Brickley
(Address)
Boston
M. D. .
Data8/4/
19
42
22 Holy Cross Malden
Place of Bur al, Cremation or Removal.
(City or Town)
DATE OF BURIAL
Aug 6 1942
19
23 NAME OF
FUNERAL DIRECTOR
Kirby Bros
ADDRESS
Winthrop
Received and filed
SEP 311000
19
(Registrar of City or Town where deceased resided)
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
1
(City or Town)
Mass GeneralHospital
John .C.
MacCormack
(If U. S. War Veteran, specify WAR)
Winthrop
(a) Residence. No .....
(Usual place of abode)
Length of stay: In hospital or institution.
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
years
Months. Days
Canada
Informant
(Address)
RM R-302
3 SEX
M
8
ÅGE.
70
9 Occupation:
12 BIRTHPLACE (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
PARENTS
(State or country)
17
Informant
(Address)
50m-10-'39. No. 8427-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
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
W
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
Sa If married, widowed, or divorced
Annie Fine
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
68
years 7 IF STILLBORN, enter that fact here.
If less than 1 day
Hours.
Minutes
Usual
Chicken Dealer
Industry
10 or Business:
Poultry( Prop).
11 Social Security No.
none
Russia
13 NAME OF
FATHER
Zelig Wolfson
14 BIRTHPLACE OF
FATHER (City)
Russia
Sarah-
Russia
weltjon, if any
A TRUE COPY
ATTEST:
Francis & 4ans
(Registrar of city or town where death occured)
DATE FILED
Aug-25-42
19
...........
months
2
days.
In this community
yrs.
mos.
2
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Aug-21-42
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
8/20/42
19
8/21/42
to ..
, 19.
I last saw h ..... im alive on
8/21-4.2
19
death is said
4 ....
to have occurred on the date stated above, at.5 ....
.13.
Immediate cause of death.
Acute Pulmonary Edema
....
Duration
hrs
Hepato renal Syndromeobstructive
Due tojaundice
Uremia
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 ?
no
If so, specify
(Signed)
Robert R. Shapiro
M. D.
(Address)
BethIsrael ... Hosp Dato8. 21 .... 19 42
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
Golden Crown Cem-Woburn
(Cemetery)
(City or Town)ass
Aug-23-42
DATE OF BURIAL
19.
22 NAME OF
FUNERAL DIRECTOR
Henry Levine
cured)
ADDRESS
Brookline ,Mass
Received and filed.
Aug-25-42
19
SEE
Hoaton 159
(City or town making return)
1
Roston
(City or Town)
No .......
Beth Israel .. Hospital
.......
St. l
$ (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Jacob Wolfson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
37 Trident Ave
.St.
Winthrop Mass
(If nonresident, give city or town and state)
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
years
Suffolkx
PLACE OF DEATH
(County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Registered No ... 6964
(Registrar of City or Town where deceased resided)
Underline the cause to which death should be charged sta- tistically.
.Date of ..
That I attended deceased from
Years.
Months
Days
RM R-302
Suffolk
PLACE OF DEATH
(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.
7036
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Edith Squire
(If deceased is a married, widowed or divorced woman, give also maiden name.)
20 Tuxburg (Jent sewing 1)
St. Winthrop Mass
(If nonresident, give city or town and state)
(Specify whether)
years
months 2
days.
In this community
yrs.
mos.
2
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
F
4 COLOR OR RACE 5 SINGLE
MARRIED
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