USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1942 > Part 80
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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 illuess 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 physi- cian is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup- posably due to injury. These include not only drathe caused directly or in- directly by traumatism (including resulting septicenria), 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 ilying, 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 im- portant, 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 ou 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 honie 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
R-301 A
1
Winthrop (City or Town)
No.
Station Hospital, .... Fort. Banks. .... Mass.
The Commonturalth 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. 247
Registered No.
$ ( If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
ERNEST. (None) REAGAN
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
If so specify WAR) World
(a) Residence. No.
General ... Delivery
St. Gatlinburg,
Tenn.
War 2
(Usual place of abode)
( If nonresident, give city or town and State)
Length of stay: In hospital or institution .:
(Before death)
(Specify whether)
O
years
0
months
3
days.
In this community
- yrs.
mos.
- days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
(write the word)
Male White
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed, or divoroed.
Unknown
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
unknown
years
7 IF STILLBORN, enter that fact here.
8
AGE ...
42 .Years ..
7.
Months.
28 .... Days
If less than 1 day
....... Hours ............ Minutes
Usual
9 Occupation :
Soldier
industry
U. S. Army
10 or Business :
11 Social Security No.
Unknown
12 BIRTHPLACE (City)
(State or country )
Gatlinburg, Tennessee
(Include pregnancy within 3 months of death)
IMPORTANT
13 NAME OF
FATHER
Unknown
Major findings:
Of operations.
None
Date of
-
Of autopsy ..
Confluent hemorrhagic
broncho pneumonia , both fung charged sta- What test confirmed diagnosis ?.
tistically.
20 Was disease or injury in any way related to oooupation of deceased ?
If so, specify.
Fleruca
(Signed).
THOMAS.F.FAY /Ist.Lt ....... M ... G .......... M. D.
(Address) Station Hospital .......
.Dat Dec ... 31,.19.12
Fort Banks, Mass.
Place of Burial, Cremation of Removal.
(City or Town)
DATE OF BURIAL
Jan
3.
29823
......
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
254 Oleag Se Reven /
(Signature of Agent of Board of Health or other) Healthe Office 1/1/43
Received and filed
.19
(Official Designation) (Date of Issue of /Permity
18 DATE OF
DEATH
December
31,
1942
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
19.
That I attended deceased from
Dec ..... 27,
19/12
to
Dec. 31,
42
i last saw him
.alive on
Dec. 31,
1942
death Is sald to
have occurred on the date stated above, at
1:10
a
m.
Immediate cause of death.
Pneumonia primary
Duration
atypical, acute, etiology unknown, severe left lower lobe.
IMPORTANT
5 days
Due to.
etiology unknown
Due to ...
Other conditions.
None
14 BIRTHPLACE OF
FATHER (City)
Unknow
(State or country)
15 MAIDEN NAME
OF MOTHER
Unknown
16 BIRTHPLACE OF
MOTHER (City)
Unknow
( State or country)
21
Relation, if any
17
Informant
(Address)
.U ...... S ..... Army.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was Issued : Wm. S. Childress
100m (d)-1-41-4667
PLACE OF DEATH
Suffolk (County)
extracts from the laws on back of certificate. terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a recital to that effeot. PARENTS
( Registrar)
Physician Underline the cause to which death should be
MEDICAL CERTIFICATE OF DEATH
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medioal officer shall forthwith, after the death of a person whom he has attended during his last illnesa, 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 belief the name of the deceased, his supposed age, the disease of which he died, defined as re- quired by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death ... Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required hy the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, aerved in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, speci- fying the war, and shall also certify in such certificate both the primary and the secondary or immediate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer shall forfeit ten dollars. For the purposes of this sec- tion and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief ex- pedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexi- can border service of nineteen hundred and sixteen and nineteen hundred and seventecn. G. L. Chap. 46, Sec. 10.
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 buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb 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 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 by law to be returned and recorded, which shall be accompanied. in case of an original internient, 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 physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate re- quired of the attending physician. If death is caused by violence, the medi- cal 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 be obtained carly 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 auch 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 hereunder. If the death certificate contains a recital, as required
by aection ten of chapter forty-aix, that the deceased aerved in the army. navy or marine corps of the United Statea in any war iu which it has been 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 neces- sary information which can be obtained as to the deceased, or aa 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 hury a human body or the ashes thereof which have heen hrought into the commonwealth until he has re- ceived 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 he buried or the funeral is to be held, or from a peraon appointed to have the care of the cemetery or burial ground in which the intermeut ia made. ... Chap. 114. Sec. 46. G. L., (Tercentenary Edition).
Medical examinera shall make examination upon the view of the dead hodies 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 hody lien and take charge of the same; ...- General Lawa, Chap. 38, Scc. 6.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rulea of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care duriug a last illneas from disease unrelated to any form of injury.
(2) Board of Health physloians 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 physi- cian is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or in- directly by traumatism (including resulting septicemia), and hy the action of chemical (drugs or poisons), thermal. or electrical agents, and deaths following abortion, but also deathis 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 cauae 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 ia very Im- portant, 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 he 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
RM R-305
PLACE OF DEATH
Suffolk (County)
Boston (City or Town) Mass General Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(City or town making return)
248
Registered No.
10720
(If death occurred in a hospital or institution,
St.
give its NAME instead of street and number)
2 FULL NAME
Joseph Katziff
(If deceased is a married, widowed .or divorced woman, give also maiden name.)
(If U. S.
War Veteran,
speolfy WAR)
(a) Residence. No.
(Usual place of abode)
11 Sea Foam Ave
St.
Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution
(Before death)
(Specify whether)
years
months
1 days.
In this community 10 yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
(Month)
(Day)
(Year)
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Celia Mussell
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife If allve 66
. years
7 IF STILLBORN, enter that faot here.
8
AGE 70 Years.
Months
Days
If less than 1 day
Hours ..
.Minutes
Usual
9 Occupation :
Watchman
Industry
10 or Business :
Nat D Stores
11 Social Security !
031-07-6301
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Hirsch Katziff
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Rachael
-
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
Relation, if any
..... i.f.e ... )
A TRUE COPY. ATTEST : (Registrar of city or town where death occurred)
20 Acoldent, sulolde, or homicide (specify) Pres acc
Date of ooourrenoe.
Dec 10/42
.. 19
Where did
Boston
Injury oocur ?
(City or town and State)
Did Injury occur In or about the home, on farm, In Industrial place, or In
publlo place?
Street
(Specify type of place)
Manner of
Injury
Struck by an auto at Boston
Nature of
On Dec 10/42 Pedestrian
Injury
While at work?
Was there an autopsy ?......
21 Was disease or Injury In any way related to oocupation of deceased ?
If so, specify.
(Signed)
Wm J Brickley
M. D.
(Address)
Boston .... Mass.
...
Date
Dec 121/42
22
Bessarbian Cem
Everett Mass
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
Dec 13, 1942
19
23 NAME OF
FUNERAL DIRECTOR
J H Levine
ADDRESS
Bo.s.t.on .... Mas.s.
Received and filed
Dec 15/42
19
(Registrar of City or Town where deceased resided)
25m (h)-1-41-4667
of the city or town in which the deceased resided as soon as possible after the close of the month in which the death resided in another city or town at the time of death should be made forthwith and transmitted on Form R-305 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
1
No.
occurred. (See Chap. 46, Sec. 12, G. L.)
17
Informant.
(Address)
DATE FILED
19
18 DATE OF
DEATH
Dec 11, 1942
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 skull Traumatic intracranial hemorrhage
1 R-302
Suffolk
(County)
1
Chelsea
(City or Town)
The Commonfocalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Chelsea
(City or town making return)
796249
St.
S (If death occurred in a hospital or institution,
give its NAME instead of street and number)
r
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
21 Pearl Av.
St.
Winthrop Mass.
(Usual place of abode)
hospital
29
(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
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
Dec . 26, 1942
3 SEX
M
4 COLOR OR RACE
5 SINGLE
(write the word)
Married
18 DATE OF
DEATH
(Month)
(Day)
(Year)
19 | HEREBY. CERTIF 42
that & afforded deceased from
1.m .... , 19.
1826
42,
19
I last saw h.
alive on
31. 05 death he said to
m.
have ocourred on the date stated above, at
Duration
Immediate
Hate caseros feath
al failure
12 hrs.
7 IF STILLBORN. enter that fact here.
69
15
If less than 1 day .Hours .. Minutes
Elevator
Operator
Usual
9 Occupation :
Industry
10 or Business :
unknown
11 Social Security No .. Dittaffald, Maas.
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
Chestor, Mass.
14 BIRTHPLACE OF
FATHER (City)
(State or country) Martha Eldredge
15 MAIDEN NAME
OF MOTHER
Mass.
16 BIRTHPLACE OF
MOTHER (City)
(State or comhospital Records
17
Informant
(Address)
(
Relation, if any
ISCemetery9, 1942
(City or Town)
DATE OF BURIAL
19
Charles h.Bennison
22 NAME OF
FUNERAL DIRECTOR
Winthrop St. Winthrop
ADDRESS
Reoelved and filed 9 19
(Registrar of City or Town where deceased resided)
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
50m (e)-1-41-4667
A TRUE COPY.
ATTEST:
Joseph a. Viersee
DATE FILED
(Registrar of city or town where dcath occurred)
Dec. 26, 1942
19
Physician
Major findings : Of operations
Date of
should be
Of autopsy
clinical
charged sta- tistically.
What test confirmed diagnosis ?
20 Was disease or injury in any way related to occupation of deceased ?
If so, specify.
(Signed)
Geo. F.Keenan
M. D.
(Address)
Soldiong! Home Date.
12/25 42
21 PLACE OF BURIALthrOP
Jem.Winthrop, Mass .
CREMATION OR REMOVAL
yr's"
Dustlorosis
Arterio sclerotic heart
Due to ..... disons0
Other conditions .......
(Include pregnaney with# 8 Months of here)
Underline the cause to which death
PARENTS
PLACE OF DEATH
No. Soldiers' Home Hospital
Henry Carter
(If U. S. War Veteran, speolfy WAR)
S.".
(a) Residence. No.
MARRIED
WIDOWED
or DIVORCED
5a If married, widowed, or divorceadamson
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
Generalized arterio
8
AGE
Years.
Months ..........
Days
.......
Registered No.
G .
A R-305
PLACE OF DEATH
Hamnden (County)
HOLYOKE (City or Town) 69 Suffolk No ...
The Commonfocalth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
HOLYOKE (City or town making return)
Registered No.
250
§ (If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
Oralter de, Drechsler
(If deceased is a married, widowed or divorced woman, give also maiden name.)
57 Emerson Road
.....
months
days.
In this community
yr3.
mos. 1 days.
18 DATE OF
DEATH.
December
30
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 am as follows: (16 an injury was involved, state fully, ) Presumably acute pulmonary Edema alceste dilation left side of hearts Compertension
20 Accident, suicide, or homicide (specify)
no
-
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?
Manner of
Injury
Nature of lajury
While at work?
.Was there an autopsy ?
21 Was disease or lajury in any way related to occupation of deceased ?
If so, specify ..
(Signed)
James Be Bigelow, M. D.
39 109 Suffolk St Date 12-30 19 42
22. Danthon
Place of Burial, Cremation or Removal.
Winthrop
(City or Town)
(2)
DATE OF BURIAL
Jan. 2
1943
23 NAME OF
FUNERAL
DIRECTOR
F. C. alger
ADDRESS.
167 Chestnut Stk Holyoke
Received and filed .
9
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.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
In
or
5a lf married, widowed, or/di
HUSBAND of
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive.
60
7 IF STILLBORN, enter that fact here.
8
58
ÅGE
Years.
Months ...
----- Days
Salesman
Usual
9 Occupation:
10 or Businessı
11 Social Security No.
028-05-50 36
12 BIRTHPLACE (City)
(State or country)
(State or country)
1
15 MAIDEN NAME
OF MOTHER
anna Sefert
PARENTS
(State or country)
25m-10-'39. No. 8427-g
after the close of the month in which the death occurred. (Sce 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
Industry
School supply Co.
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
Or DIVORCED Married
(write the word)
Clara Dr. Hodgkins
(Give maiden name of wife in fully
Years
lf less than 1 day
Hours.
.Minutes
Butternut
Wisconsin
13 NAME OF
FATHER
Hermann Drechsler
14 BIRTHPLACE OF
FATHER (City).
Cannot be learned
16 BIRTHPLACE OF Cannot be learned MOTHER (City)
17 Mro, Clara Or. Drechsler (iv)
Informant
(Address)
inthron mass.
Å TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED Dec. 31 19 42
MEDICAL, CERTIFICATE OF DEATH
(11 U. S.
War Veteran,
specify WAR)
St.
Winthrop mass.
(If nonresident, give city or town and state)
years
O Relation, if any
(Specify type of place)
١٠
RM R-301 ||
State Board of Health Bureau of Vital Statistics
CERTIFICATE OF DEATH
NON RESIDENT
COPY
DECEASED:
(a) State
(b) County Suffolk
(c) City or Town
Winthrop
(If outside city or town limita, write RURAL)
(d) Street No.
36 Temple Aven
(d) Name of hospital or institution 620 3rd ste 900
20
(If rural, give location)
(e) Citizen of Foreign country? NO
yes or no
If yes, name country
3. FULL NAME OF DECEASED
FRANCIS LEON REED
3 (a) If veteran,
3 (b) Social Security
name war None
No. 706-09-6529
4. Sex Male 5. Color or race White
6. Single. married, widowed or divorced Widowed
6 (a) If married, widowed or divorced, husband of (or)
5a If m HUSBAN
wife of Elizabeth Burke
6 (b) Age of husband or wife, if alive Deceased years
(or) WI
7. Birth date of deceased Un obtainable
(month)
(day)
(year)
6 Ago o 7 IF STI
8. Age: Years
Mouths
Days
If less than one day
70
hrs.
min.
Usua 9 Occu
9. Birthplace Burlington, Vt.
(City, town or county) (State or foreign country)
10. Usual occupation Retired embalmer
11. Industry or business
Funeral
11 Socio
12. Name
2 2 Reed
12 BIRTE (Sta 13 R
14. Maiden name Jennie Le Deaux
of sutopsy
(Give date of operation) X
Underline the cause to which death sheuld be charged xta- tistically.
22. If death was due to external causes, fill in the following:
a) (Probably) Accident, suicide, homicide (specify) X
'(b) Date of occurrence
(c) Where did injury occur?
(City or town) (County) (State)
17 (a) Date June 22nd 19412 . 17 (b) Place Winthrop Mass
18. Funeral Director's Signature With Ralph G. Cooksey Funeral Home We Wczes
18 (a) Address St. Petersburg ELA.
(Specify type of piace) While at 2. Signature Chain B. Cawpa MQ,
(1) Address St .Petersburg Date Signed
6/20/42
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed.
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