USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1945 > Part 32
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No undertaker or other person shall bury a human body or the ashes thereof which have been brought Into the commonwealth until he has re- ceived a permit so to do from the hoard of health or its agent ajywinted to Issue such permits, or if there is no such hoard, from the clerk of the town where the body is to be buried or the funeral is to he held, or from a person appointed to have tbe care of the cemetery or burial ground in which ibe internient is made. ... Cbap. 114. Sec. 46. C. L., (Tercentenary Editiou).
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 Ifes and take charge of the same; ... - General Laws, Chap. 38, Sec. 6.
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 deatba 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 aa those of persons who, though disahled by recognized disease unrelated to any form of injury. have died without recent medical attendance or whose pbsaf- cian is ahsent from home when the certificate of death is needed.
(3) Medioal Examiners will investigate and certify to all deaths sup- posably due to Injury. These include not only deaths caused directly or in- directly by traumatiam (Including resulting septicemfa), and hy the action of chemical (drugs or poisons), thermal, or electrical agents, sind deaibs following abortion, but also deaths from diseass resulting from Injury or Infection related to occupation, the sudden deaths of persons not disablad hy recognized disease, and those of persons found dead.
Statement of Cause of Death .- Cause of deathi meana the disease, or complication which causes death. not the mode of dying, e. g., heart fallure, asphyxia, asthenia, etc. Aa 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 Oooupation .- Precise statement of occupation fs very fm- portant, so that the relative bealthfulness of various pursuits cant 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 Illuese. If the deceased had retired from business, report the usual occupation prior to retirement. Children not gainfully employed may be returned an at school or at borne. For a woman wbose only occupatiou was that of home bousework, write bousework. 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
M R-302
1
PLACE OF DEATH
Middlesex (County)
Stoneham (City or Town) New Eng. San. & Hosp. No.
The Commonmoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Stoneham (City or town making return)
Registered No.
54 91
(If death occurred in a hospital or institution, St. give its NAME instead of street and number) 1
2 FULL NAME
Mary Frances Cusolito nee' SantoSpirito
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No.
355 Winthrop
St.
Winthrop
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In hospital or institutlodo.s.p.i.t.al ...
(Before death)
(Specify whether)
years
months
24 days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE|
white
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
widowed
5a If married, widowed, or divoroed
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
John Cuisolito
(Husband's name in full)
6 Age of husband or wife if alive
years
7 IF STILLBORN, enter that fact here.
8
AGE
64
Years
2
Months
.Days
If less than 1 day Hours .. Minutes
Usual
9 Occupation :
Housewife
Industry 10 or Business :
11 Social Seourity No ..
12 BIRTHPLACE (City)
Lipari
(State or country)
Italy
13 NAME OF
FATHER
Joseph SantoSpirito
14 BIRTHPLACE OF
Lipari
FATHER (City)
(State or country) Italy
15 MAIDEN NAME
OF MOTHER
Angela Cusolito
16 BIRTHPLACE OF
MOTHER (City)
Lipari
(State or country)
Italy
17 Hospital record
Relation, if any
Informant
( Address)
A TRUE COPY.
ATTEST :
( Registrar of city or town where death occurred)
April 7,
19
45
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
April
4 ,
1945
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
Feb.
15
19 ... 4.5., to
April .... 4
19 ... 4.5 ..
I last saw h .... e.r ..... alive on.
April
4
19.4.5 death Is sald to
have occurred on the date stated above, at
11:19 p .m.
Duration
Immediate cause of death
Surgical shock
36 hrs
Due to
Operation for cancer
of rectum
6 mos.
Due to
Other conditions.
(Include pregnancy within 3 months of death)
Major findings :
Of operations.
Cancer of Rectum
Date
0
4/3/45
Physician 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 occupation of deceased ?... O
If so, specify
(Signed)
Arthur
.L. Tauro
M. D.
(Address) Mala.en ....... Mas.s ..
Date
4/ 4 19
45
21 PLACE OF BURIAL,
St. Michaels, Boston
CREMATION OR REMOVAL
(Cemetery)
april 7,
(City or Town)
19
4.5
DATE OF BURIAL
22 NAME OF
FUNERAL DIRECTOR
Leo M. Norton
ADDRESS
Malden, Mass.
Reoelved and filed
MAY 1. 5 1015
1.9
(Registrar of City or Town where deceased resided)
1
DATE FILED
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 12-302 to the clerk copies vi trung vi uals recrue during the previous month which occurred in your city or town in case the deceased
50m (e)-1-41-4667
PARENTS
That I attended deceased from
....
-
R-302 1
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
25M-(f)-11-42 10746
PLACE OF DEATH
Middlesex
(County)
Tewksbury, Mass.
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Tewksbury State Hospital and .. Infirmary. (City or town making return)
Registered No.
108.92
(C'ity or Town) Tewksbury State Hospital and Infirmary No.
(If death occurred in a hospital or institution,
St.
give its NAME instead of etreet and number)
Elizabeth Larkin
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residenoe. No.
125 Cliff Avenue
Winthrop
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution.
(Before death)
(Specify whether)
years 10 months 19 days.
In this community
yre.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE|
White
5 SINGLE
(write the word)
18 DATE OF
DEATH
April
18
1945
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
That I attended deceased from
May 29
...
19. 4.4, Apr ....... 18.
19.
.4.5
I last saw h.e.r.
.. alive on
Apr
18.
. 19.45
h Is sald to
have occurred on the date stated above, at
8:40 A .... m.
Duration
6 Age of husband or wife If alive years
7 IF STILLBORN, enter that faot here.
8
.. 69
AGE.
.Years
6
Months
0
.Days
If less than 1 day
Hours ..
.Minutes
Usual
9 Oooupation :
Housework
Industry
10 or Business :
11 Social Security No.
12 BIRTHPLACE (City)
Not .... leg.nnod
(State or country)
England
13 NAME OF
FATHER
William P. Larkin
PARENTS
FATHER (City)
....
(State or country)
England
15 MAIDEN NAME
OF MOTHER
Anne Cochrane
16 BIRTHPLACE OF
MOTHER (City)
Not learned
(State or country)
England
17 Hospital Records
Relation, if any
Informant
(Address)
A TRUE COPY. C. Winthrop Houghton Supt.
ATTEST :
(Registrar of city or town where death occurred)
DATE FILED
April 18
45
19
Immediate cause of death
Medullary Carcinoma of Rt.
Breast with Metastases
? 17
Yrs.
Due to.
Old Cerebral Hemorrhage
with Right Hemiplegia
Due to.
Hypertensive Heart
Disease
Other conditions
Diabetes Mellitus
(Include pregnancy within 3 months of death)
Physician
Major findings :
Of operations
Date of
should be
charged sta-
Of autopsy
Biopsy and
tistically.
What test confirmed dlagnosis?
Clinica.1
20 Was disease or Injury in any way related to oooupation of deceased ?
If so, speolfy
Lois B. Crowell
(Signed)
M. D.
(Address)
T. S. H. and I. Tewksbury
Dat 4 ..... 18 .19 45
21 PLACE OF BURIAL.
St. Joseph, W. Roxbury
DATE OF BURIAL
(City or Town)
19
45
22 NAME OF
H. L. FArmer and Son
FUNERAL DIRECTOR
ADDRESS
Tewksbury, Massachusetts
Received and filed 19
(Registrar of City or Town where deceased resided) 1945
Underline the cause to which death
14 BIRTHPLACE OF
Not learned
MARRIED
WIDOWED
or DIVORCED
Single
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband'e name in full)
(If U. S.
War Veteran,
speolfy WAR)
1
CREMATION OR REMOVAL
(Cemetery)
April 21
301 A
If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requirss physicians to Insert a recital to that effeot. PARENTS
100m(i).1-44.13634
PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registared No.
St.
(If death occurred in a hospital or institution,
{ give its NAME instead of street and number)
2 FULL NAME
Daisy L (Reid) Wilcke
( If deceased is a married, widowed or divorced woman, give also meiden name.)
(a) Residenca. No.
457 Shirley Street
St.
( If nonresident, give city or town and State)
Length of stay: In hospital or Institution
( Before death)
Hosp.
yeers
months
2
days.
27
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)
Female
White
MARRIED
WIDDWED
or DIVORCED
Married
(Month)
(Day)
(Year)
Thet I attended deosased from
19 | HEREBY CERTIFY,
April 30,
19 45 to.
May 2
1945
I last saw her alive on
May
2,, 19 42, death is said to
have occurred on the date stated above,
at
11.50 ?
.m.
6 Age of husband or wife if aliva 63
years
7 IF STILLBORN, enter that fect here.
8
AGE
57 Years
9 Months
17 Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation :
Housewife
Industry
10 or Business :
Own Home
11 Social Security No. None
12 BIRTHPLACE (City)
( State or country)
Canada
13 NAME OF
FATHER
John Reid
14 BIRTHPLACE DF
FATHER (Clty)
(State or country)
Ireland
15 MAIDEN NAME
OF MOTHER
Margaret Mathews
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
17 Henry H Wilcke
Informent
( Address)
457 Shirley St.
I HEREBY CERTIFY that a setisfeotory stendard oartifloate of deeth wes filled with me BEFORE the burial or transit dermit was Issued : Im & lechildress
HO
(Signature of Ageat af Board of Health or other) may 4/ 43
(Dftela) Designation) ( Date of Frase of Permit)
20 Was disease or injury in any way related to oogupation of deceased ? If so, spoolfy
200
( Signed)
( Address)
Winthrop, Dass
Date MAY/ 194) Winthrop
21
Winthrop
(City or Town)
DATE OF BURIAL
22 NAME OF
Howard SOSynolds
FUNERAL DIRECTORY
ADDRESS
Winthrop mais .
Received and fled MAY 5 1945 .. 19
( Regletrar)
938
Other conditiona.
( Include pregnancy within 3 months of deeth)
IMPORTANT
Major findings :
Of operations
Date of
Of autopsy
What test confirmed diegnosis?
Clinical Signs
Duration
immedlate cause of death
Cerebral Hemorrhage
IMPORTANT April 30 .....
Due to
Due to
Hypertension
Physician Underline the cause to which death should be charged sta- ristically.
M. D.
Plece of Buriel, Cremation or Removel.
May 5
45
19
Husband ry
1
No. Winthrop Community Hospital
To be filed for burial permit with Board of Health or its Agent.
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(Usual place of abode)
( Specify whether)
18 DATE OF
DEATH
May
2
1945
5a If married, widowed, or divoroed
HUSBAND of
(or) WIFE of
Henrfiverr iwi Takewife in full)
( Husband's name in full)
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 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 furnisbing a certificate of death as required by 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, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert iu 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 expedition 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 Mexican border service of nineteen hundred and sixteen and nine- teen hundred and seventeen. 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 tomh other than the receiving tomh 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 sball 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 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 pbysi- 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 buman body, not previously interred, from one town to another within tbe 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 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 bereunder. 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 been 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 neces- sary 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).
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 hody lies and take charge of the same; . . . - General Laws, Chap. 38, Sec. 6.
No undertaker or other person shall bury a human body or the ashes thereof which have been brought 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 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 hedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose phy- sician 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 indirectly hy 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., beart failure, asphyxia, astbenia, 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 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, how- ever, 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-303-A
1
1
PLACE OF DEATH
(City or Town) (4) Court Road
The Commonmealth 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.
Registered No.
95
St. { (If death occurred in a hospital or institution, ( give its NAME instead of street and number)
PHYSICIAN ~ IMPORTANT
2 FULL NAME.
(If deceased is a married, widowed or divorced women, gjve also maiden name.) .
(a) Residence. No.
14) Court Rd. Hunthat.
St.
(Usual place of abode)
: Length of stay: In hospital or Institution ..........
...
years
months
days.
In this community
yrs.
mos.
48 days.
3 x
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
White
4 COLOR OR RACE|. 5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Single
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
. (Husband's name in · full)
6 Age of husband or wife If allye years
7 IF STILLBORN, enter that faot here.
8
AGE
Years
1
Months.
18
Days
If less than 1 day
Hours .........
Minutes
Usual
9 Occupation :
Industry
10 or Business :
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
Massachusetts
13 NAME OF
FATHER
Robert H. Reid
14 BIRTHPLACE OF
FATHER (City)
East Boston
(State or country)
Massachusetts
15 MAIDEN NAME
OF MOTHER
Lillian Jackman
16 BIRTHPLACE OF
MOTHER (City)
Med ford
(State or country)
Massachusetts
17 Robert H. Reid
Informant
Fathery
( Address) 147 Court Road Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burlal er transit permit was Issued: L
(Signature of Agent of Board of Health or other)
lactic Ofsteel 5 /4/1hs
(Official Designation) (Date of Issue of Permit)
20 Acoldent, sulolde, or homloide (specify).
accidental
Date of ooourrenoe.
man -3-
19 40
Where did
Injury ocour ?
(City or town and State)
Did Injury ooour In or about home, on farm, In Industrial place, or In publlo
place?
(Specify type of place),
Injury
Manner of Found dead in his lassenette
Nature of Injury
While at work?
Was there an autopsy?
200
21 Was disease or Injury In any way related to occupation of deceased?
If so, specify
Hm f. Buckley
(Signed)
(Address)
Basta 2. Jebio -3-
,
M. D.
22 Winthrop Winthrop
Place of: Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
May 4
1.945
19
23 NAME OF
FUNERAL DIRECTOR
Winthrop Massachusetts
John F. Omaley
ADDRESS
Received and filed
19
MAY 5 .1945
(Registrar)
If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to Insert a reoital to that effect
PARENTS
50m (g)-1-41-4667
so that it may be properly classified under the International Classification of Causes of Death. See reverse side for
extracts from the laws relative to the return of certificates of death.
Su/kk
(County)
No.
James Brian Reed REID
(Was deceased a
U. S. War Veteran,
If so specify WAR)
(If nonresident, give city or town and State)
(Before death)
(Specify whether)
18 DATE OF
DEATH
Way -5-1945
(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 a astheation Que to cool artund necio y/2
5
.
LA
+
1
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City of Town)
No. Winthrop Community Hospital
St.
To be filled for burial permit with Board of Health or its Agent.
Registrar's No.
97
§ (If dcath occurred in a hospital or institution, { give its NAME instead of street and number) PHYSICIAN-IMPORTANT (Was deceased a U. S. War Veteran,
if so specify WAR).
(a)
Residence. No.
29 Plummer Ave.
St.
(If nonresident, give eity or town and State)
Length of stay: In hospital or Institution.
(Before death)
(Specify whether)
years - months 8
days.
In this community 35yrs.
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 Widowed
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Betty Peterson
(Husband's name in full)
have occurred on the date stated above, at.
6 P:
M.
6 Age of husband or wife if alive.
years
Immediate causesof death ..
aceite Cormay Monetirais
Duration IMPORTANT
3 days
8 AGE75 Years. Months
6 Days
If less than 1 day
Hours ..
Minutes
Usual
9 Occupation :
Stationary Engineer
Industry
10 or Business:
Pumping Station
11 Social Security No. . none
12 BIRTHPLACE (City)
(State or country)
Sweden
13 NAME OF
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