USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1942 > Part 8
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SPACE FOR ADDITIONAL INFORMATION
RM R-303A
MARGIN RESERVED FOR BINDING
25m-2-'40-D-729-b
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: William D. Childrens
(Signature of Agent of Board of Health or other)
Cegent Clam 31/42
(Officlal Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Jamen 31-1942
(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.)/ asphyxiature: Posituace Positie.2.4
20 Accident, suicide or homicide (specify) accidental
Date of occurrence.
Jun - 31-
19 4R -
Where did
Injury occur?
(City or Town and State)
Did injury occur in or about home, on farm, in industrial place, in public place?
(Specify type of place)
Manner of
Injury.
Found dead in mother led
Nature of
Injury.
While at work?
.Was there an autopsy ?....
21 Was disease or injury in any way related to occupation of deceased ?.
If so, specify
They Suckle
M. D.
(Signed)
Date - 31-191/2
(Address)
22 ...
solyhard
Place of Burial, Cremation or Removalo (City or Town)
DATE OF BURIAL
February
1
47 19.
23 NAME OF
FUNERAL DIRECTOR
7
ADDRESS
867 Beacon St Rollo
19
1000
(Registrar)
1 of Death. See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of PARENTS
PLACE OF DEATH No
Suffolk ((County) Huitturbo (City or Town) . 60 Quece CK
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
19
Registered No. § (If death occurred in a hospital or institution, { give its NAME instead of street and number)
2 FULL NAME.
Thomas
harris fr
(If deceased is a married, widowed or divorced woman, give also maiden name.)
60 Queria Que Hutterop
(If nonresident, give city or town and state)
In this community
-
yrs.
1
mos.
23
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
make White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single
Sa 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 GE ... - .Years 1 Months. 23 Days
If less than 1 day Hours Minutes
Usual 9 Occupation : none
Industry 10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
nuss
13 NAME OF
FATHER
Thomas J. Morris
14 BIRTHPLACE OF FATHER (City) (State or country)
Button
mais
15 MAIDEN NAME
OF MOTHER
Catherine Grady
16 BIRTHPLACE OF MOTHER (City) .... (State or country)
Winthrop
Relation, if any
17 mis Catherine manife mother Informant. (Address) 60 Quincy avec Winthrop
St.
(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.
Received and filed
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 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 body in a town, or remove therefrom a human hody 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 hoard, 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 tomb 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 be issued until there shall have been delivered to such board, agent or clerk, as the case may he, a satisfactory written statement containing the facts required hy law to be returned and recorded, which shall he 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 be obtained early enough for the purpose, or is in- sufficient, a physician who is a member of the board of health, or em- ployed hy it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner 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 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 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 re- moval of such body 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 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 furnish for registration any other necessary information which can he obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chop. 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 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).
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence. If a medical examiner has notice that there is within his county the body of such a person, he shall forthwith go to the place where the body lies and take charge of the same; . . . - General Laws, Chap. 38, Sec. 6.
... He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residence, if known; other- wise a description as full as may be, with the cause and manner of death. -General Laws. Chap. 38, Sec. 7.
. The medical examiner certifies the cause and manner of death to the best of his knowledge and belief.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the 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 ahsent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly hy traumatism (including resulting septicemia), and hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, hut also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disahied hy recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause, the nature of an injury and of its consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas hacillus) caused by a steam railway accident." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic." "Fracture of the skull with asso- ciated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the cir- cumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous, of the hrain (basal ganglia) (found dead in hed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person).
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have met his death by violence, until a permit, signed by the Medical Examiner, has first been obtained .- General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
RM 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
after the close of the month in which the death occurred. (Sce Chap. 46, Sec. 12, G. L.)
PLACE OF DEATH
Middlesex (County)
The Commonturalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Cambridge (City or town making return)
Registered No.
86
20
(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME
Samuel White
(lí deceased is a married, widowed or divorced woman, give also maiden name.)
158 Cliff Axe.
St.
Winthrop
Length of stay: In hospital or institution.
(Specify whether)
months
2
days.
(If nonresident, give city or town and state)
In this community&yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
Or DIVORCED
(write the word)
Married
5a If married, widowed, or divorced HUSBAND of
Sylvia
..... Robbins
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive ...
34
Years
7 IF STILLBORN, enter that fact here.
8
AGE
43
Years
Months.
Days
If less than 1 day
Hours ....
Minutes
Usual
9 Occupation:
Meat Market
Prop
Industry 10 or Business:
11 Social Security No.
none
12 BIRTHPLACE (City)
(State or country)
Russia
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Underline
Gangrene ... of smallthe cause to
intestin68
Date of.
1/20/42
which death
should be
charged sta-
What test confirmed diagnosis ?.
X ... Ra.y.
tistically.
Dora Cannot be learnedgo Was disease or Injury In any way related to occupation of deceased ?
no
If so, specify
(Signed) ....
Emanuel dontsch
M. D.
(Address) 469 Beacon St.
Date] . .. 21
19.42
17
Informant.
Sylvia White
watha, if any
(Address)
158 Cliff Ave. Winthrop Mass . DATE OF BURIAL
Jan 23, 1942
19
A TRUE COPY.
ATTEST:
Jan 22. 1942
(Registrar of city or town where death occurred)
Frederick it Park
DATE FILED 19
18 DATE OF
DEATH
Jan 21, 1942
(Month)
(Day)
(Ycar)
19 I HEREBY CERTIFY.
That I attended deceased from
Jan .... 16
19 ... 42 to ..
.....
Jan 20
194.2
I last saw h ..... m ... alive on ..
Jan 20
19.42, death is said
to have occurred on the date stated above, at.
12 30m.A Duration
Immediate cause of death
Intestinal obstruction
4 ... days
Due to
internal abdominal
hernia
Due to
Congenital .... banda
13 NAME OF
FATHER
Jacob White
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21 PLACE OF BURIAL,
CREMATION OR REMOVAL .... Adath .... Jeghwin
hp (Cemetery)
vest
22 NAME OF
FUNERAL DIRECTOR
Manuel Staneteky
ADDRESS.
10 Washington St. Dor
Received and filed
20 1 2 912
19
(Registrar of City or Town where deceased resided)
50m-10-'39. No. 8427-f
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
1
Cambridge
(City or Town)
-
No ..... Cambridge Hospital
.......
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No ..
(Usual place of abode)
Hoap.
years
(Give maiden name of wife in full)
PARENTS
Of autopsy
RM 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 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.)
50m-10-'39. No. 8427-f
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
21
(City or town making return)
Registered No.
798
5 (If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
Michael
Rose.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
180 Shirley
St.
Winthrop
(If nonresident, give city or town and state)
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
single
(write the word)
18 DATE OF
DEATH.
Jan 26 1942
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY.
1/20/42
19
........ , to .........
That I attended deceased from
1
26/42
19
I last saw h ....... M.alive on ..
1/26/42
.....
19.
, death is said
to have occurred on the date stated above, at.
1/10P
m.
Duration
Immediate cause of death
prematurity
1 dy
8
AGE
Years
Months.
1.
Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation:
Industry 10 or Business:
Il Social Security No ...
12 BIRTHPLACE (City)
(State or country)
Winthrop Mass
13 NAME OF
FATHER
Michael Rose
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston Mass
15 MAIDEN NAME
OF MOTHER
Anna Croll
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston Mass
17
Informant ..
(Address)
father
Relation, if any
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
1/29/42
19
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)
WIFranke
M. D.
(Address)
Boston
Date ]/26/1942
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
Beth Joseph Woburn
DATE OF BURIAL
Jan 27 1942
19
22 NAME OF
FUNERAL DIRECTOR
M Stanetsky
ADDRESS.
Boston.
Received and filed.
03 1 0 1942
19
(Registrar of City or Town where deceased resided)
should be charged sta- tistically.
Due to
Due to
6 Age of husband or wife if alive. 7 IF STILLBORN, enter that fact here.
years
MEDICAL CERTIFICATE OF DEATH
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
PARENTS
Date of
(Cemetery) (City or Town)
FAY
No. The Infants ... Hospital
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No ......
(Usual place of abode)
Length of stay: In hospital or institution.
(Specify whether)
RM R-305
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
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
25m-10-'39. No. 8427-g
PARENTS
15 MAIDEN NAME
OF MOTHER
Margaret Sullivan
IG BIRTHPLACE OF
MOTHER (City)
Ireland
(State or country)
17
Informant
(Address)
Charlotte Cronan-
Relation, if any
sistef
DATE OF BURIAL
Jan 31 1942"
19
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
2/2/42
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Jan 28 1942
(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.)
Fractured .... skull
probably accidental fall
alcoholism
20 Accident, suicide, or homicide (specify).
Date of occurrence.
Jan 26 ?
19
42
Where did Injury occur ?. Boston town and State)
Did injury occur in or about the home, on farm, in industrial place, or in
public place ?
street?
Manner of Injury
Nature of Injury
While at work ?
Was there an autopsy ?
yes-head
21 Was disease or lajury la any way related to occupation of deceased ?
I' so, specify.
(Signed)
Timothy Leary
.
M. D.
(Address)
Boston
Date
1/29/ .42
22 Cambridge
Camb
Place of Burial, Cremation or Remo;al.
(City of Town)
23 NAME OF
FUNERAL DIRECTOR
O P Doonan Sons
Malden
ADDRESS
Received and filed.
2. 1 0 1942
19
male
white
MARRIED
WIDOWED
or DIVORCED
(write the word) widowed
Sa If married, widowed, or divorCatherine Haley HUSBAND of
(Give maiden name of wife in full)
(or) WIFE cf
(Husband's name in full)
6 Age of husband or wife if alive.
years
7 IF STILLBORN, enter that fact here.
AGE
8 7.2 Tears
Months.
Days
If less than I day
Hours.
Minutes
Usual
9 Occupation:
retired
Industry
10 oz Business:
house painter
Il Social Socurity No.
12 BIRTHPLACE (City)
(State or country)
Malden Mass
13 NAME OF
FATHER
John A Cronan
14 BIRTHPLACE OF
FATHER (City)
Ireland
(State or country)
22
PLACE OF DEATH
BOSTON
(City or Town)
Boston City Hospital
(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 ma.den name.)
395 Shirley Ave
..... ......... St. Winthrop
(If nonresident, give city or town and state)
VIS.
mos. days.
(Specify whether)
years
months
days.
In this community
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
1
4 COLOR OR RACE 5 SINGLE
John
Cronan
(If U. S. War Veteran, specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or institution ..
No. .......
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF (City or town making return) MEDICAL EXAMINER'S CERTIFICATE OF DEATH Registored No. 9.0.2
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
(Specify type of place)
(Registrar of City or Town where deceased resided)
RM R-302
Suffolk
PLACE OF DEATH
(County)
The Commontoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON
(City or town making return)
9.28
23
(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.)
17 Cutler
St.
Winthrop Mass
(a) Residenoo. No.
(Usual place of ahode)
(If nonresident, give city or town and State)
Length of stay: In hospital or institution
(Before death)
years
months
days.
in this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE|
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEParried
5a If married, widowed, or divoroed Sarah Sandler
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Hushand's name in full)
6 Age of husband or wife if alive 70 years
7 IF STILLBORN, enter that fact here.
8
AGE
Years
Months.
Day
If less than 1 day Hours Minutes
Usual
9 Occupation :
real estate
Industry
10 or Business :
11 Social Security No .....
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Nathan Bloomberg
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Russia
(State or country)
15 MAIDEN NAME
OF MOTHER
Sarah -
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17 Informant. .Harry .... Bloomberg. (. Relation, if any son
(Address)
A TRUE COPY.
ATTEST :
Errances
(Registrar of city or town where death occurred)
.19
22 NAME OF
FUNERAL DIRECTOR
B F Solomon
ADDRESS
Brookline
Received and filed B 1) 1942 19
DATE FILED 2/3/42
18 DATE OF
DEATH
Jan 30 1942
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY,
1/13/42
19
to
1/30/42
19
I last saw h .... j.m ..... alive on.
1/30/42
19
death Is sald to
have ocourred on the date stated above, at .. 9/40P m.
Immediate oause of death congestive heart failure
Due to.
rheumatic heart disease
yrs
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- tistically.
Of autopsy
What test confirmed diagnosis?
20 Was disease or injury in any way related to ocoupation of deceased ?.
If so, specify
(Signed)
A J Linenthal
M. D.
(Address)
Boston
Date 1/30/1942
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
(Cemetery)
(City or Town)
DATE OF BURIAL
Feb 1 1942
19
50m (e)-1-41-4667
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
of the city or town in which the deceased resided. (See Chap. 16, Sec. 12, G. L.)
1
(City or Town)
No.
Beth Israel Hospital
Hyman
Bloomberg
(If U. S.
War Veteran,
speolfy WAR)
male white
That I attended deceased from
Duration
3 yrs
69
(Specify whether)
Registered No.
Crawford
W Rox
(Registrar of City or Town where deceased resided)
RM R-301 A
PLACE OF DEATH
Sufflok
(County)
1
Winthrop
(City or Town)
(a) Residence. No.
145 Herman
....
(Usual place of abode)
Length of stay: In hospital or institution ..
Hospital
(Specify whether)
3 SEX
4 COLOR OR RACE
MARRIED
WIDOWED
or DIVORCED
White
Male
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
38
7 IF STILLBORN. enter that fact here.
8
41
9
Months
5
AGE
Years
Days
Usual
9 Occupation :..
Assembler
10 or Business :.
11 Social Security No.
021-10-1467
Last
Boston
12 BIRTHPLACE (City)
(State or country)
Mass .
13 NAME OF
FATHER
James Turner
14 BIRTHPLACE OF
FATHER (City).
Lewiston
(State or country)
Maine
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
PARENTS
MOTHER (City)
San Francisco
(State or country)
California
17
James Turner
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
(Signature of Agent of Board of Health or other)
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of
Industry
Automobile Factory
100m-2-'40-D-729-a
5 SINGLE
(write the word)
18 DATE OF
DEATH
Feb
2
1942
(Month)
(Day)
(Year)
19
I HEREBY CERTIFY.
That I attended deceased from
Jam 27
1942, to Feb 2
19 42
last saw hw alive on Feb 2
19 .. 5.2, death is said to
have occurred on the date stated above, at ..
1.23 A.
.m.
Immediate cause of death ....
Bacterial Bacteria
Endocarditis
Duration IMPORTANT 4 dias .....
Due to Bronchitis
Due to.
Double nihal Cesion
Other conditions ... Chanie Rheumatic Heart Disease (Include pregnancy within 3 months of death)
40: you IMPORTANT
PHYSICIAN
Underline the cause to which death should be charged sta- tistically.
Was disease or injury in any way related to occupation of deceased ?.
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