USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1947 > Part 17
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(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, hut also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled hy 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 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, 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
RM R-302
Suffolk (County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Revere
(City or town making return)
Registered No.
48
(If death occurred in a hospital or Institution,
give its NAME instead of atreet and number)
2 FULL NAME.
Mary C. Boris
(Callahan)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
50 Pleasant
SŁ
Winthrop
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution
(Before death)
Conv. Home
years
months
days.
In this community
yrs.
mos.
days.
(Specify whether)
8 Weeks
8 Weeks
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Femal
4 COLOR OR RACE
White
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widow
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
Aug.
16
19 ..
to
46
That I attended
Feb.
24
deceased
19
I last saw h .... @T ...... allve on ..
Feb.
2.3 19.4.7, death Is sald to
have occurred on the date stated above,
8:00A
.m.
Duration
Immediate cause of death.
Chronic ... Rheumatic
Heart Disease
Due to ..
Due to.
Industry
Retired Housewife
10 or Business:
11 Soois! Security No .....
None
12 BIRTHPLACE (City)
(State or country)
Mass.
13 NAME OF
FATHER
Daniel Callahan
PARENTS
15 MAIDEN NAME
OF MOTHER
Catherine (Unknown)
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 D. Callahan
Informant
( Address)
B484HAY
50 Pleasant St. Winthrop
A TRUE Copy Left Shill
ATTEST :
(Registrar of city or town where death occurred)
Feb.
27
147
22 NAME OF
FUNERAL DIRECTOR
Kirby ... Bros
Winthrop
ADDRESS
Winthrop St.
MAR 7
19.47
19
(Registrar of City or Town where deceased reskled)
50m-(b).6.44-14607
of the city or town in which the deceased resided. (See Obap. 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-808 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
Revere
(City or Town)
214 Endicott Ave.
St.
(If U. S.
War Veteran,
No
specify WAR)
(a) Residence. No.
(Usual place of abode)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Raphe live Bude name of wife in full)
(Husband's name in full)
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that fact here.
AGE
8
: 86
Years
.Months.
Days
If less than 1 day Hours Minutes
Usual
9 Ocoupation :
At Home
Other conditions ... Senility
(Include pregnancy within 3 months of death)
Physiclan Underline the cause to
Mejor findings:
Of operations
which death
Date of
should be charged sta- tistically.
Of autopsy What test confirmed diagnosis? Clinical Signs 20 Was disease or Injury In any way related to occupation of deceased ?.
NO
If so, spoolfy
Daniel J. O'Brien
(Signed)
(Address)
Winthrop
Date
2/2519
....
M. D.
47
21 PLACE OF BURIAL,
CREMATION OR REMOVAL .
Winthrop Cem. Winthrop
(Cemetery)
(City or Town)
. DATE OF BURIAL
February
2.6
19
47
Received and filed.
DATE FILED
18 DATE OF
DEATH
February
24, 1947
40 Yrs.
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
Boston
PLACE OF DEATH
No.
RM R-302
1
PLACE OF DEATH
Suffolk (County) Boston
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
18431 0
No.
(City or Town)
Peter Bent Brigham Hospital
St.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
Phillip Kaufman
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
54 Shore Drive
St.
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution.
(Before death)
(Specify whether)
years
monthal2
days .
In this community
yrs.
mos. 12 days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE|
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Husband's name in full)
70
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that faot here.
8 AGE 73 Years Months. Days
If less than 1 day Hours .Minutes
Usual
9 Oooupation :
Merchant
Industry 10 or Business :
Groceries-Wholesale
11 Soolal Seourity No. None
Russia
12 BIRTHPLACE (City)
(State or country)
13 NAME OF FATHER Alfred Kaufman
14 BIRTHPLACE OF
Russia
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Elizabeth
Russia
17 Informant (Address)
A KaufmannRelationSonny
DATE OF BURIAL
Feb.25/47
Everett ... Mass. (City or Town) 19
22 NAME OF
FUNERAL DIRECTOR
Henry Levine
ADDRESS
Brookline Mass.
(Registrar of city or town where-death-cocufred)
DATE FILED
(
Feb. 27/47/
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
Feb. 24/47
(Day)
(Year)
19 | HEREBY CERTIFY,
Feb/11/47
19.
to ..
That66 24947 eased from
19.
I last saw h ..... 1m .... allve on
Feb.24/47
19
death Is said to
4,25AM
m.
Duration
Immedlate oause of death. Arterio sclerotic heart disease
Yrs .....
o1d.
Cardiac infarct
otd.
Due toMural thrombus
Phlebothrombosis rt.leg
Dupulmonary embolism, bilateral
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.
Of autopsy What test confirmed diagnosis ?... autopsy ... 20 Was disease or Injury In any way related to oooupation of deceased ? NO.
If so, spoolfy
(Signed).
R.A ... Wilhelm
(Address) Peter B. Brigham Hosph. 2-24
19
M. 87
21 PLACE OF BURIAL fareth Israel of Winthrop,
CREMATION OR REMO
(Cemetery)
50m- (b) .6.44-14607
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-808 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. 46, Sec. 12, G. L.)
PARENTS
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
A TRUE COPY.
ATTEST: Nicklas
Reoelved and filed
MAR 10 1947
19
(Registrar of City or Town where deceased resided)
(If U. S.
War Veteran,
speolfy WAR)
Winthrop Mass.
(Usual place of abode)
Lena Greenberg
(Give maiden name of wife in full)
have ooourred on the date stated above, at
F
which death
RM R-303-A
+ Julio. /(County)
1
Mutteroh
(City or Town)
No.
2 FULL NAME
(Usual place of abode)
Sinead upon assen
3 SEX
Female White
5a If marrled, widowed, or divoroed
HUSBAND of
(or) WIFE of
6 Age of husband or wife If allve
7 IF STILLBORN, enter that fact here.
8
AGE 62 Years
4
Months.
13 Days
Usual
9 Occupation :
10 or Business :
11 Soolal Security No.
12 BIRTHPLACE (City)
(State or country)
PARENTS
If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a recital to that effect
extracts from the laws relative to the return of certificates of death.
so that it may be properly classified under the International Classification of Causes of Death. See reverse side for
should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms,
50m. (f)-6-43-12056
N. B .- WRITE PLAINLT, WITH ONFADING DLAGR INK-IMIS IS A PERMANENT RECORD. Every Tem er menteTion
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
4 COLOR OR RACE| 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Widowed
(Give maiden name of wife in full)
Condon
(Husband's name in full)
years
If less than 1 day Hours ........... .Minutes
Howchuper
Industry
Private family
13 NAME OF
FATHER
Michael J. Riley
15 MAIDEN NAME
OF MOTHER
mary Cusack
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Informant Russian Chiudere(raccolta" (1dilimen ) Lander ave Rara
I HEREBY CERTIFY that a satisfactorystandard certificate of death was filed with me BEFORE the burial or transit permit was Issued:
Healthe Officer 2/26/47
(Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
(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.)
acute Cardiac Facture
Ceramic Myocarditis
20 Accident.
sulolde, or homioldo (specify)
Date of ooourrenoe.
.19
Where did
Injury ooour ?
(City or town and State)
Did Injury ooour In or about home, on farm, In Industrial place, or In publio
place ?
(Specify type of place)
Manner of
Collapsed while walking.
Injury
Injury
Nature of
un street + died qui dle
While at work ?
Was there an autopsy ?.
21 Was disease or Injury In any way related to occupation of deceased ?
If so, speolfy
The J. Trickley
M. D.
(Signed) ...
(Address)
Bonten
Joly 25€
19 47
22
Cedargrove
Peabody
Place of Burial, Gremation or Removal.
(City or Town)
Relation, IfAny
DATE OF BURIAL
Feb 28, 1947
19
23 NAME OF
FUNERAL DIRECTOR
Johan @ Donovan
ADDRESS
Reoolved and filed
MAR : 47
19
(Signature of Agent of Board of Health or other)
The Commonmoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burlal permit with Board of Health or Its Agent.
Registered No.
50-
St. ( ( If death occurred in a hospital or institution, { give its NAME instead of street and number)
ann Jane Condon
(If deceased is a marfied, widowed or divorced woman, give also maiden name.)
PHYSICIAN-IMPORTANT
(Was deceased a
U. S. War Veteran,
If so specify WAR).
(a) Residenoe.
No.
503 Central Str Sangues Ision
(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
(write the word)
18 DATE OF
DEATH
Jean- 25-1947
(Registrar)
PLACE OF DEATH
Mutterale Community (tropitalie
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medloal offioer shall forthwith. after the death of a person whom he has attended during his last illness, at the request of an undertsker or other authorized person or of any mieniber of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the naine 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 slive by the physician or officer and the date of his death ... Gen. Laws, Chap. 16, 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 humired 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 engageil, tusert 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 immediste cause of death as nearly as he can state the sante. F'or 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 sectinns forty-five, forty-six and forty seven of said chapter one hundred and fourteen, the word "war" shall include the ('hina relief ex- pedition sud the Philippine insurrection, which shall, for ssid purposes, be deemeil to have taken place between Feliruary fourteentli, eighteen hundred and ninety-eiglit and July fourth, nineteen hundred and two, and the Mexi- can border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Cbap. 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 perinit froin the board of health, or ite 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 exhunre a human body and remove it from a town, from one cemetery to anotlier, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until be has received a permit from the board of health or its agent aforessid or from the clerk of the town where the liody 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 Isw. or in lieu thereof a certificste as hereinafter provided. If there is 10 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, sliall upon application make the certificate re- quired of the attending physician. If desth is caused by violence. the medical exsininer shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to an- other within the coninouwesith cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the pos- session of the undertaker desiring to inske 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 re- movsi, unless a permit in the ususl form for the reinoval 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 sppesr upon the permit. The board of lrealth, or its sgent, upon receipt of such statement and certificate, shalt forthwith countersign it aml transmit it to the clerk of the towir for regis- tration. The person to whom the permit is so given and the physician cer- tifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may re- quire .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has re- ceived a permit so to do front 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 boily is to be huricd or the funeral is to be held, or from a per- son appointed to have the care of the cemetery or burial ground in which the intermeut is niade. ... Chap. 114, Sec. 46, G. L., (Tercentenary Edi- tion).
Medical examiners shsll mske 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 hia 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; otherwise 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 illnesa from disease unrelated to any forin of injury.
(2) Board of Health physiclans 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 medicsl attendance or wbose physi- cian is absent from horne wlieu 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 deatby caused directly or in- directly by trauinatism (including resulting septicemia), and by the action of chemical (drugs or poisons). thermal, or electrical agents, and deaths following abortion, but siso desths from disease resulting from Injury or Infeotion related to occupation, the sudden deaths of persons not disabled by recognized disease, and linse 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: "Com- pound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway sccident." "Pistol shot wound of the chest with asso- cisted hemorrhage, hoinicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether adininistered as a surgical anaesthetic." "Fracture of the skull with associated internal injury sus- tained 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 ita known or presuinable nsture; snd (2) uneler manner, indicate the circum- stances leading to medico-legal inquiry. For example : "Hemorrhage spon- taneous of the brain ( hasal ganglia) (found dead in bed)." "IHeart 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
ORM R-302
1
PLACE OF DEATH
Essex (County)
Danvers
(City or Town)
No.
Danvers State Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
(City or town making return)
Registered No.
51
(If death occurred in a hospital or inetitution, St.
2 FULL NAME
Mary G. Mccarthy
(McCormick)
give its NAME instead of street and number)
7
(If U. S.
War Vataran,
speolfy WAR)
(If deceased ie a married, widowed or divorced woman, give also maiden name.)
(a) Residanoa. No.
9] Lowell Ra
St.
Winthrop
Mass
(If nonresident, give city or town and State)
Langth of stay: In hospital or Institution
(Before death)
4
years
10monthe
10days.
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)
MARRIED
WIDOWED
or DIVORCED Widowed
5a If marrlad, widowed, or divoroed HUSBAND of
(or) WIFE of
Dan i (Giye maiden, neme of wife in full)
(Husbend's name in full)
6 Age of husband or wifa If allve years
7 IF STILLBORN, entar that faot here.
8
AGE 74
Yaars
Months.
Days
If less than 1 day
.Hours
.Minutas
Usual
9 Occupation :
Housewife
Industry 10 or Business:
11 Soolal Security No .... o.n.e .::
Boston
12 BIRTHPLACE (City)
(State or country)
Mass
13 NAME OF
FATHER
Thomas McCormick
14 BIRTHPLACE OF
FATHER (City)
Halifax, N. D.
(State or country)
Canada
15 MAIDEN NAME
OF MOTHER
Jane Callahan
16 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
MASS
21 PLACE OF BURIAL,
CREMATION OR REMOVALOId Calvary
Boston
(Cemetery )
(City or Town)
DATE OF BURIAL February.
13
19.4.7 ..
22 NAME OF
FUNERAL DIRECTOR
Richard C. Kirby
ADDRESS
Boston, Mass
Reoelved and filed
MAR 1 2 1947
19
(Registrar of City or Town where deceased reelded)
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
Copies of returns of deaths recorded during the previous month which occurred in your city or town In case the deceased
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.)
PARENTS
50m. (b) -6-44-14607
A TRUE COPY.
ATTEST :
(Registrar of city or town where death occurred)
DATE FILED
Feb.
1.9
19.4.7
18 DATE OF
DEATH
February
11
1.9.4.7
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
Feb
4
19 .... 46,
Teb ..
7.7
That I attanded daoaased from
... 194.7 ..
I last saw h ..
er .... allve on.
Feb.
.. 11.
.19 .. 4.7 daath Is sald to
have ooourred on the data stated above, at.
12.45 A. m.
Immedlate causa of death.
Arteriosclerotic heart disease
5y.r.s.
Due to.
Dua to.
Other conditions.
(Include pregnancy within 3 months of death)
Physician Underline the cause to which death
Major findinge:
Of operations
Date of
should be cherged sta- tietically.
What test confirmed diagnosis ?.
Clinical
20 Was disease or Injury In any way related to oooupation of daoeased ?
If so, speolfy
(Signed) ...... Francis .......... Sullivan
M. D.
(Address) Hathorne, Mass
Dato ..
/.21
19.47
17
Mary K.McPhillips ... (
Informant
(Address)
Hathorne Mass
Relation, if any
......
...........
(Usual place of abode)
(Specify whether)
Duration
Of autopsy
+
COPY OF CERTIFICATE OF DEATH
DEPARTMENT OF COMMERCE Bureau of the Census
STANDARD CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE
Town or City
Clerk's No.
52.
FULL NAME
1. PLACE OF DEATH:
(a) County
Cheshire
(b) City or town
Keene
(c) Name of hospital or institution:
Elliot Community Hospital
(If not in hospital or institution write street number or location)
(d) Length of stay:
Few Hours
In hospital or institution
(Specify whether years, months or days)
Few Days
In this community
(Specify whether years, months or days)
3. (a) If veteran, name war
(b) Social Security No.
4. Sex
Female
5. Color or race|
Whi te
6. (a) Single, widowed,
21. I HEREBY CERTIFY that I attended the deceased from
19.
married, divorced
Wid owed
19
to
.....;
6. (b) Name of husband or wife:
James Edward Thompson
(Full name-Maiden name. if wife)
6. (c) Age of husband or wife, if alive
years
7. Birth date of deceased
February
28
1875
(Month)
(Day)
(Year)
8. AGE: Years|Months
72
0
Days
0
If less than one day
hrs.
min.
9. Birthplace
Cambridge
Massachusetts
(City, Town. or County)
(State or Foreign Country)
10. Usual occupation
At Home
11. Industry or business
-
12. Name
Alfred George Austin
FATHER
13. Birthplace
Oxford
England
(City, Town, or County) (State or Foreign Country)
14. Maiden name Sarah Margetts
15. Birthplace Woodstock, Ungland
(City. Town, or County) (State or Foreign Country) 16. (a) Informant's own signature .Mr.s .... Lucille Smitho.
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