USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1945 > Part 77
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(City or town making return)
9106
231
Registered No.
( If death occurred in a hospital or institution, give its NAME instead of street and number)
The resa Vesce
(If deceased is a married, widowed or divorced woman, give also maiden name.)
127 Cottage Park Rd
St.
Winthrop Mass.
(If nonresident, give city or town and State)
mos.
days.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDMarried
(Cive maiden name of wife in full)
Frank .... Vesce
(Husband's name in full)
6 Age of husband or wife If allve 85 years
If less than 1 day Hours .. .Minutes
13 NAME OF
FATHER
Domenic Astrella
17
Informant.
(Address)
son. ( Relation, if any
1
2 FULL NAME
(a) Residenoe. No.
(Usual place of abode)
Length of stay: In hospital or Institution.
(Before death)
3 SEX
4 COLOR OR RACE|
Female
White
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
7 IF STILLBORN, enter that fact here.
8
Usual
9 Occupation :
Housewife
Industry
10 or Business :
at home.
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
Italy
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
15 MAIDEN NAME
OF MOTHER
PARENTS
16 BIRTHPLACE OF
MOTHER (City)
Italy
(State or country)
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-305 to the clerk
AGE ..
79
Years
Months
Days
of the city or town in which the deceased resided as soon as possible after the close of the month in which the death
occurred. (See Chap. 46, Sec. 12, G. L.)
years
months
days.
In this community 23
yrs.
(If U. S. War Veteran, speolfy WAR)
M. D.
M R-302
FULK
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or town making return)
Registered No.
968232
St. (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME .... Samuel .... Pelofsky (If deceased is a married, widowed or divorced woman, give also maiden name.)
(If U. S.
War Veteran,
speolfy WAR)
(a) Residence. No.
23 Wave Way Ave. Winthrop Mags.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution ....
Hosp .......
years
months
In this community
yrs.
mos.
29days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE|
white
5 SINGLE
(write the word)
Single
MARRIED
WIDOWED
or DIVORCED
5a If married, widowed, or divoroed
HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if allve
years
7 IF STILLBORN, enter that faot here.
Months Days
If less than 1 day
Hours.
.....
.Minutes
Usual
9 Ocoupation :
Shipper
10 or Business:
Wholesale ..... Wall ..... Paper
11 Soolal Seourity No .....
010-03-2586
12 BIRTHPLACE (City)
(State or country)
Chelsea Mass.
13 NAME OF
FATHER
Joseph Pelofsky
Russia
15 MAIDEN NAME
OF MOTHER
Lena G. Kraft
Russia
17 Max Pell
Relation, if any .. Brother .. )
Informant
(Address)
358 Walnut Ave. Roxbury
Mass
A TRUE COPY.
ATTEST :
Nov. 14, 1945
(Registrar of city or town where death occurred)
DATE FILED .19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
No.v ....... 11, ..... 1945
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY, That I attended deceased , from
Oct. 21
19.45,
to ..
NO.V ...
11
1945.
19 ...
I last saw him ailve on NOV.
11
LLSdeath Is sald to
have occurred on the date stated above, at.
11:35 Pm.
Duration
Immedlate oause of death ..... Amyotrophic .... lateral
sclerosis & Asthenia
5 years
Due to.
Due to.
Other conditions.
quadriplegia aphasia
(Include pregnancy within 3 months of death)
S VIS Physician
Underline the cause to
Major findings:
Of operations
None
.Date of
should be
Of autopsy
What test confirmed diagnosis ?.
Clinical
20 Was disease or Injury in any way related to oooupation of deceased?
If so, speolfy
(Signed)
Dave ..... Glunts
(Address) Franklin
GardensDate 11/12/ 45
21 PLACE OF BURIAL,
CREMATION OR REMOVAL ...
Beth ... Israel ... Cem.
Everett Mass . (Cemetery)
DATE OF BURIAL
(City or Town)
Nov ......... 1.3.,.
19.45.
22 NAME OF
FUNERAL DIRECTOR
H.J. Torf
ADDRESS
1.51.Washington ... Ave ..... Chelsea.
Received and filed.
JAN 7 1946
19
(Registrar of City or Town where deceased resided)
1
1
PLACE OF DEATH
BOSTON
(County)
(City or Town)
No.
Jewish Memorial Hosp.
(Before death)
(Specify whether)
3 SEX
Male
(or) WIFE of
8
AGE ..
38 Years
Industry
14 BIRTHPLACE OF
FATHER (City)
16 BIRTHPLACE OF
PARENTS
MOTHER (City)
(State or country)
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-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
(State or country)
50m- (b) .6.44-14607
which death
charged sta- tistically.
R-302
1
PLACE OF DEATH
6 (County)
(City or Town)
No.
Mass. Memorial Hospital
(If death occurred in a hospital or institution,
St.
give its NAME instead of street and number)
2 FULL NAME
Susan Bostrom
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual place of abode)
68Sunnyside 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
6 days.
In this community
yrs.20 mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
Whitel
4 COLOR OR RACE|
(write the word)
18 DATE OF
DEATH
Nov 16/45
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
11/10/45, 19
...
That i, attended deceased from
to ... 11/16/45
19
I last saw h ............ allve on
11. 16/45 19
death Is sald to
have ocourred on the date stated above, at
1,57 ... a.m.
Duration
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that faot here.
8
AGE
.1 .... Years .... 8 ......
Months .. 15.
Days
If less than 1 day .. Hours. Minutes
Usual
9 Ocoupation :
None
Industry 10 or Business :
11 Soolal Seourity No.
12 BIRTHPLACE (City)
(State or country)
Winthrop Mass.
13 NAME OF
FATHER
Herman Bostrom
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Boston Mass:
(State or country)
15 MAIDEN NAME
OF MOTHER
Gwendolyn Baker
16 BIRTHPLACE OF
MOTHER (City)
Beverly Mass
(State or country)
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
Winthrop
Winthrop
(Cemetery )
(City or Town)
DATE OF BURIAL
N.o.v ..... 19./45
19
22 NAME OF
FUNERAL DIRECTOR
H ... S .... Reynolds
ADDRESS
Winthrop Mass.
Reoelved and filled 19
JAN / 1370
(Registrar of City of Town where deceased resided)
10m- (b) .6.44-14607
17 Informant. (Address)
Father ( ... Relation, if any
A TRUE COPY.
ATTEST :
mas to ".
(Registrar of city or town where death occurred)
DATE FILED
Nov 19/45
19
Sing
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Immediate cause of death.
Ac ute lymphatic lekemia
1 mo
Due to.
Due to.
Other conditions
(Include pregnancy within 3 months of death)
Physician
Underline the cause to
Major findings :
Of operations.
Date of
should be
charged sta- tIstically.
What test confirmed diagnosis ?.
20 Was disease or Injury In any way related to oooupation of deceased ?.
If so, speolfy
C A Powell
(Signed)
M. D.
(Address)
Bost.a
Date .. 11./16/4.5.
which death
Of autopsy
above
autopsy
resided in another city of town at the time of death should be made forthwith and transmitted on Form R-sox to the clerk of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
Registered No.
9809 233
(If U. S.
War Veteran,
speolfy WAR)
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or town making return)
R-302
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
50m. (b) -6.44-14607
PLACE OF DEATH
(County)
1
...
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTO
(City or town making return)
Registered No.
(If death occurred in a hospital or inetitution, St.
give its NAME instead of etreet and number)
2 FULL NAME Hannah Rubin
(If deceased is a married, widowed or divorced woman, give also maideu name.)
(a) Residence. No.
(Usual place of abode)
......
3.9 ..... Forre.s. Ist. 3 ........
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution ..
(Before death)
(Specify whether)
years
1
months
days.
25
In this community, 7
yrs.
moe.
daye.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE|
White
5 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
10/2/45 19
to
11/27/45, 19
That
J attended deceased from
I last saw h
eltve on.
1.1 ... .. 27 19 ... 4.5death Is sald to
have occurred on the date stated above, at
5.407.
Immedlate cause of death
Carcinoma of the uterus with
metastases to the bones by
61
8
AGE
Years
Months.
Dayı
If less than 1 day
.Hours.
Usual
9 Occupation :
Housewife
Industry
10 or Business :
at home
11 Soolal Security No .....
12 BIRTHPLACE (City)
(State or country)
Palestine
13 NAME OF
FATHER
Joseph Bornstein
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Kate Appleman
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
17
informant.
(Addrese)
husband ...
Relation, if any
A TRUE COPY.
ATTEST: 04
(Registrar of city or town where death occurred)
DATE FILED TOV 00/495
What test confirmed diagnosis ?.
20 Was disease or Injury In any way related to occupation of deceased ?
If so, specify
no
(Signed)
Berman
M. D.
(Address
Boston
Data1/27/195
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Beth .... Ha ... drash
DATE OF BURIAL
(Cemetery )
NOV 28/49
(City or Town)
19
22 NAME OF
FUNERAL DIRECTOR
L Levine
ADDRESS
Brookline
Received and filled JAN 7 1946 .19
(Registrar of City of Town where deceased resided)
Physician Underline the catee to which death should be charged sta- tistically.
Major findings :
yrs
Of operations
none
Date of.
Of autopsy
A-Ray and Biopsy
Duration
6 Age of husband or wife If allve
.6.3 years
Minutes Due to.
Due to
Other conditions.
Decubitis ulcers in
(Include pregnancy within 3 months of death)
sacral region hypertension
PARENTS
BOS
No.
Jewish Memorial Hospital
(If U. S.
War Veteran,
spoolfy WAR)
18 DATE OF
DEATH
NOV 27/45
5a if married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Joseph Rubin
(Husband's name
7 IF STILLBORN, snter that fact here.
:
مـ
R-301
terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and
extracts from the laws on back of certificate.
100m-(g)-1-45-15510
I HEREBY CERTIFY that a satisfactory standard deftificate of death was filed with me BEFORE the burial or transit permit was issued:
6
........... (St mature of Agent of Board of Health os ethet)
Health Officer 12/4/45
(Official Designation) ( Date of Those of Pernht)
18 DATE OF
DEATH
DEe. 2.1945.
. (Jfonth )
(Day)
(Year)
Sa If married, widowad, or divoroed HUSBAND of
(or) WIFE of
Thereis no me Hle erwan
( Husband's name in full)
6 Age of husband or wife if alive 5/ yaers
7 IF STILLBORN, enter that fact hera.
€ AGE 4-8 Years Montha Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation :
House wife
Industry
10 or Business :
own home
11 Social Security No. none
12 BIRTHPLACE (City)
( Siate or country)
E UST Boston
-mark
PARENTS
14 BIRTHPLACE OF
FATHER (CHY)
(State or country)
Freland
15 MAIDEN NAME
OF MOTHER
Sarah Ann Edeson
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
21
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
December 5,
1945
22 NAME OF
FUNERAL DIRECTOR
John T.Kelly
ADDRESS
11 Meridian St., E. B. 0
Received and Alad.
NFC 1 1945
19
( Registrar)
If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
1
PLACE OF DEATH
Suffolk (Granty) Winthrop
(City or Towpy, 21 Palmyra
The Commonwealth 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.
235 ....
[ (If death occurred in a hospital or institution, St.
{ give its NAME instead of street and number)
C
2 FULL NAME
mary
Kirwan
PHYSICIAN - IMPORTANT
(Was deceased a
WU. S. War Veteran,
20
(If deceased is a married, widowed,or divorced woman, give also maiden name.) 21 Palmyra
(e) Residenca. No.
(Usual place of abode)
260
years
months
days.
In this community
4 yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
( write the word)
Married
1901 HEREBY CERTIFY.
face 1.
19
to WEe. 2.
19
Thet I ettended daosased from
Vi Jast saw h
Er
alive on
2
19 y .. death is said to
have occurred on the date stated above, at.
6 %-A.
Duration
Limite Pulmon ideme
Due to.
Chinoui hydraulites
2
Due to.
Other conditiona
( Include pregnancy within 3 months of death)
IMPORTANT
Major AndIngs:
Df oparations
Date of.
Of autopsy
What test confirmed diagnosis ?
To
20 Was diseasa og injury in any way ralatad to occupation of decaasad ? if so, spacity .........
M. D.
(Address) 19 Inquesto SF ENS Date 12/3
19.5/
Thou. . Ifferwany severband
17 Informant ( Address) 21 Palmana St., win
13 NAME OF
FATHER
John Riley
Physician
Underline the cause to which death should be charged st .. tistically!
1
st
Winthrop
"if-so specify WAR)
(If nonresident, give city or town and State)
Length of stay: In anspital or Institution
( Before death )
( Specify whether)
Registered No.
No.
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 furnishing 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 in the certificate 2 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 relicf 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 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 be 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 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 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 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 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 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 body 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 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 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 by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Cause of death means the disease, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause.
Statement of Occupation .- Precise statement of occupation is very 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
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
R-301 A
If deceased was a U. S. War Veteran, G. L. Chap. 45. Seotion 10, requires physiolans to Insert a reoltal to that effeot. 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
1
(County) UnithRop (City or Torn) 20
"WAVE WAY THE.
The Commonwealth 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.
236 ...
{ (If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
William I. MCILROY
( If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residenca. No.
20 WAVE WAY
E st.
( If nonresident, give city or town and State)
Length of stay : In hospitel nr Institution
(Before death)
( Specify whether)
years
months days.
In this community 28 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 -
50 If marrled, widowed, or divorced
HUSBAND of
Emma & Baston
Grde maiden name of wife in full)
(or) WIFE of
( Husband's name in full)
6 Age of husband or wife if elive 75 years
7 IF STILLBORN, enter that fect hera.
8 71
Years
7
Months
20 Days
If less than 1 dey
Hours
Minutes
Usual
9 Occupellon :
RETIREd. PRINTER
Industry 10 or Business :
11 Social Security No.
12 BIRTHPLACE (City)
( State or country)
Boston mass
13 NAME OF
FATHER
Robert MCILROY
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Scotland
1
PARENTS
15 MAIDEN NAME
OF MOTHER
Elizabeth -
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
41.4
STRE
17 Informent. ( Address) Emma meIlRoy
( with
I HEREBY CERTIFY that a satisfactory standard certificate of death was Aled with Ma BEFORE the burist or tranzit permit was Issued :
1
(Signature of Agent of Board of Health or other)
Mater pasidal (Omdelai Designation) ( Date of freue of Permity
1215/59
18 DATE OF
DEATH
( Month)
Y
1945
(Year)
19
HEREBY CERTIFY,
19
Thet 1 attended deoeased from
to
19
i last saw h alive on 19 death is said to
have occurred on tha date stated above, at m.
Duration
Immediate oouse of death
IMPORTANT
Due to
Due to
Other conditiona.
( include pregnancy within 3 months of death)
Major findings: Of operations
Date of.
Of eutopsy
What test confirmed diagnosis?
IMPORTANT
Physician
Underline the cause to which death should he charged $2.1 - tistically.
20 Was disease or injury in ony way related to occupation of deceased ?
If so, spaolfy
(Signed )
( Address)/M
BAN, Date /2/ 19
6
JANGUS MASS
..... . M. D.
21 RIVERSIDE
Piace of Buriil, Cremation or Removal
DEC. 62
( Gity or Town)
DATE OF BURIA
19
45
Howard S. Krym
If (VR)
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
188 unchip stumbling
19
Received and Ated
DEC 6 1945
( Registrar)
100m.(x).1-45 15510
20 Wave Way QUEM
Relation, If any
Registered No.
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
2 FULL NAME
No. PLACE OF DEATH Suffolk
(Usual place of abode)
(Day)
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
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