USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1953 > Part 4
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Chap .: 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the follow- -ing 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 fo any form of injury.
(2). . Board of , Health physicians will certify to such deathsonly as those of persons who, though disabled by recognized disease unrelated to any form of injury, Have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) . Medical Examiners will investigate and certify to all deaths supposably due to injury." These include not only deaths caused directly or indirectly 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 ssadded deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very import- ant, 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 occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. 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, 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.
ASPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
M R-302 1
PLACE OF DEATH
Suffolk
(County) Boston
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
10
Boston
(City or town making return)
538
Registered No.
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME Herbert Rich
(If deceased is a married, widowed or divorced woman, give also maiden name.)
11 ... Dwight St
St.
(If nonresident, give city or town and State)
Length of stay: In place of death.
......... years ....
months.
days.
In place of residence.
3 ... years ...
.. months
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
(Month)
Jan/18/53
(Day)
(Year)
4I HEREBY CERTIFY.
That I attended deceased from
Jan/16 19 ..
53
to
Jan.1.8 ..
19
SB
I last saw h
imlive on
Jan.18 .... 19 ....... 5death is said to
have occurred on the date stated above, at.
5:30Am.
INTERVAL BE-
(Husband's name in full)
TWEEN ONSET AND DEATH 11 IF STILLBORN, enter that fact here.
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a)
Pulmonary tuberculosis
12
AGE
Many
57
Months.
Days
If under 24 hours
Hours.
Minutes
Months ? 1 Yr. Occupation: Musician
(Kind of work done during most of working life)
14 Industry
or Business:
Self.
15 Social Security No.
None
16 BIRTHPLACE (City)
(State or country)
Boston Mass
OTHER
SIGNIFICANT
Cirrhosis of liver (Laennec'a)
Yrs
What test confirmed diagnosis ?.
Xrays .... of chest and po
sputa
5 Was disease or injury in any way related to occupation of deceased ?....
(Signed)
Jacob Matloff
M. D.
Boston City Roept 1-2019 5B
Winthrop vem Winthrop Mass
6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Jan. 20/53
19
7 NAME OF
FUNERAL DIRECTOR
M W Kirby
Winthrop Mass.
ADDRESS.
4-4353
Received and filed 19
PPARENTS
25M-(B)-11-51-905807
C
=
(Registrar of City or Town where deceased resided)
17 NAME OF
FATHER
Gilbert, W Rich
18 BIRTHPLACE OF
FATHER (City).
East Boston Mass.
itivesate or country)
19 MAIDEN NAME OF MOTHER Elizabeth Wilson
20 BIRTHPLACE OF
MOTHER (City)
North Truro Mass.
(State or country)
21
Informant
(Address)
W .... Rich
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Jan. 21/53
.....
19
3 DATE OF DEATH CEDENT (b) CAUSES Major findings: Of operations. If so, specify. (Address) Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible, CONDITIONS
advanced active
ANTE
Due To
Due To (c)
Date of operation.
Was autopsy performed? No
10a If married, widowed, or divorced HUSBAND of
Mildred Harris
(Give maiden name of wife in full)
(or) WIFE of.
(Was deceased a
U. S. War Veteran,
if so specify WAR).
Dorchester Mass.
17 W #1
(a) Residence.
No.
(Usual place of abode)
(City or Town)
South Dept. Boston City Hospt.
No.
Married
6
FEB. 9
Entered Service Dec.26,1917 Dis charged Sept.30,1921 at Boston Musician Ist Class U S Naval Reserve 183-33-56 at Boston Mass.
X
PLACE OF DEATH
Essex (County)
1
Beverly
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Beverly
(City or town making return)
11
Registered No.
f(If death occurred in a hospital or institution,
St.
give its NAME instead of street and number)
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
(Usual place of abode)
150 Shore Drive
St.
Winthrop ... Mass
(If nonresident, give tity or town and State)
Length of stay: In place of death
years
months.
days. In place of residence.
20
.. years
months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
January 29, 1953
DEATH
(Month)
(Day)
(Year)
9 SEX
Male
10 COLOR OR RACE
White
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word) Married
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.)
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AGE
65%
Months.
Days
If under 24 hours
Hours
Minutes
5 Accident, suicide, or homicide (specify).
Date and hour of injury. .19.
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
(Specify type of place)
Manner of
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed?
No
6 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
Whitman G. Stickney
M. D.
(Address) Beverly, Mass. Date.
1/30
Bessambian Cem. Everett, Mass 7 Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL Feb. 1. 19
53
Informant ..
(Address)
5 Loris Rd., Danvers
8 NAME OF
FUNERAL DIRECTOR
10 Washington St., DorchesterTEST:
A TRUE COPY.
5.
Thomas H Scanlan
ADDRESS
Received and filed. January 30, 1953 .19 - FEB 1 0. 1953
(Registrar of City or Town where deceased resided)
(Registrar of City or Town where death occurred)
Agent 1/30/53
DATE FILED
19
3
M R-305
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) 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
25m-(h)-10-48-24658
m's
No PARENTS
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
20 MAIDEN NAME
OF MOTHER
Bessie Cannot be learne
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
22 Benjamin Halpern
17 BIRTHPLACE (City).
(State or country)
Russia
18 NAME OF
FATHER
Jacob Halpern
15 Industry
or Business:
For himself
16 Social Security No.
031-05-3771
Millinery Store
14 Usual
Occupation :
(Kind of work done during most of working life)
... Coronary disease. Pulmonary edema
in hospital less than 24 hours
No. Beverly Hospital
Samuel Halpern
Benjamin Bimback
11
Si
1
6 5
IBER
FEB10 PM
M R-301A -
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
12
No. Winthrop Community .... Hospital
J(If death occurred in a hospital or institution,
St. [ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME Eleanor R. Collins (Ardini).
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. .87 Endicott ....... ve .....
St.
Revere
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death years. months. .days. In place of residence 1.7years . . months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
10 SINGLE
(write the word)
Femalel White
MARRIED
WIDOWED
or DIVORCEarried
10a If married, widowed, or divorced
HUSBAND of ..
(Give maiden name of wife in full)
(or) WIFE of Daniel J. Collins
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING Pulmonary
TO DEATH (a)
Emboli
ANTE
Due To
Rheumatic Heart
CEDENT (b)
CAUSES
Disease
Due To (c)
INTERVAL BE- TWEEN ONSET ANO DEATH 1 week 12 AGE .44 Years Months Days 11 IF STILLBORN, enter that fact here.
If under 24 hours
Hours
.. Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
at home
15 Social Security No ..
none
16 BIRTHPLACE (City)
(State or country)
Mass
Boston
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
une
Date of operation
.. Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or)injury in any way related to occupation of deceased?
If so, specify ......
(Signed) John 7 Collins
(Address) Kever Mars
Date Jan 31
1953
6 .Holy Cross
Malden
Place of Burial or Cremation (City or Town)
DATE OF BURIAL. Feb .... @ , ... 1953 19
7 NAME OF
FUNERAL DIRECTOR ( schall ). for illa
ADDRESS
876 Winthrop Ave. Revere
Received and filed
FEB 1053 19
(Registrar)
PARENTS
17 NAME OF FATHER James Ardini
18 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Louise Cuneo
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass
21 Informant Daniel J. Collins
(Address)
87 Endicott Ave., Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Walter A. Lakers.
(Signature of Agent of Board of Health or other)
(Official Designation)
(Date of Issue of Permit) 2/3/03
3 DATE OF
DEATH
January
31
1953
(Month)
(Day)
(Year)
4I HEREBY CERTIFY,
53
That I attended deceased from
December 1 1952
to ..
Hemay 31
19
I last saw
h
en January 31, 1953 death is said to
have occurred on the date stated above, at 11:15 Pm.
moun since 1951
50m-(b)-11-49-900,560 C
RUCTIONS FOR . CERTIFICATE giving OF DEATH ot enter than one for each (b) and (c)
does not mean of dying, such ilure, asthenia .. ans the disease, ications which th.
id conditions. ving rise to the se (a) stating rlying cause
itions contrib- e death but not the disease or causing death.
2/2/53
To be filed for burial permit with Board of Health or its Agent.
(Was deceased a U. S. War Veteran, if so specify WAR)
16
M. D.
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 required 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 a recital to that effect, specifying the war; and shall also certify in such certificate both the primary and the secondary or. imme. diate 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 section 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; he: deemed to have taken place between February fourteenth, eighteen hundredfand ninety-eight and July fourth, nineteen hundred and two, and the Mexican. Border service of nineteen hundred and sixteen and nineteen 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-te issee 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 shallexhume 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 inter- ment, 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 physician 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 required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot 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 registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can 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 cxamination upon the view of the dead bodies of persons as arc supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. - General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so. to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried Ar the funeral is to be heldl, or from a person appointed to have the care of the cunctory or burial ground in which the interment is made.
. Chap. 114, Scc. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
-The fulfillment of the purpose of these laws calls for the observance of the follow- ing. fules 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 Lito-any form of injury.
(2) Board of Health physicians will certify to such deathsonly as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly 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 .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very import- ant, 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 occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. 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, 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
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
CONNECTICUT STATE DEPARTMENT OF HEALTH Bureau of Vital Statistics - Hartford, Connecticut, U. S. A.
COPY
Certificate of Death
1 PAMAN OF DEATH
State of Connecti u (b) County.
d) Le of stay
in tobe
(If n t in hospital give street no. or lot ti n)
Name f H pital Gr. New Haven Comm Hospital r I titution
3. NAME OF D AS D Type r print
Fır t) MAURICE
PERSONAL AND STATISTICAL PARTICULARS
7. SINGL WIDOWED,
5. SEX M B . RACH W.
MARRIED DIVORCED
8. IF MARRIED, WIDOWED OR DIVORCED, GIVE MAIDEN NAME OF WIFE OR HUSBAND
Anne Cohen
(Month) (Day)
Year)
9. DATE OF D TH JAN. ~ 1953.
10. DATE OF BIRTH
AGE
n years
If u der 1 year
f under 1 day
last birthday)
Months Days Hors Mins,
Dec. 1, 1893 59
11. BIRTHPLAC (City or town) WINTHROP
MASS
12. (a) USUAL OCCUPATION (Give kind of work done durin , most of working life even if retired)
Salesman
(b) Industry or Business
Knitted Wear
13. (a) WAS DECEASED A VETERAN? Yes or NoNO
(b) If yes, give war.
Unit or Ship
FATHER
14. NAME Harry Newman 1 (City or town)
(State or foreign country) N. Y.
MOTHER
16. NAME __
MAIDEN Theresa Olinsky (City or town) (State or foreign country)
17. BIRTHPLACE New York N Y
18. INFORMANT'S NAME
Donald J. Newman
19. BURIAL, CHETHAT OF ROWYM Date Jan. 2, 19 53
Cemetery of Crem mrs. Hebrew Cemetery
Place Boston, Mass. 20. NAME OF EMBALMER IF BODY WAS EMBALMED
License number
Harry Weller 21. SIGNAN RE OF LI ENS DEM ALM ROR LICENSED FUCK RAL DIRECTOR
650
Larry Heller New Haven 11, Conn.
Ad
Auduur Gasolina- REGISUN
Registrar.
I certify that this is a true copy of the certificate received for record.
Andrew Carolina
ttest :
January
BY
2. USUAL RESIDENCE OF DECEASED:
MASS.
(b) County_
(d) (City er Borong-)
If rural ve location)
trest
N ber
19 CROSS St.
(Last)
4. SOCIAL SECURITY NUMBER
Newman
MEDICAL CERTIFICATION
22. CAUSE OF DEATH at the - wie perine (a) DISEASE OR CON DURRETE LA ING - DEATH Ths doe tarihe - de f daing, ch as heart com piscats hi- caused death
coronarie
Disegu
ANTECEDENT CAUSES, Morbid auditions, if any thing rise to the etoss cause (a) stating the underlying cause last.
DUE b) TO, arterioscler osis
DUE c) TO. .
23. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related to the disease or condition causing death
24. OPERATION, DATE AND MAJOR FINDINGS
AUTOPSY (Yes or No) no
25. IF DEATH WAS DUE TO EXTERNAL CAUSES, FILL IN THE FOLLOWING: (b) Date of occurrence
(a) Accident, suicide. homicide (specify) ..
(c) City or Town and State Where injury occured
(d) Did injury occur in or about home, factory, (e) While at work?
farm, office, street, etc .?.
(f) How did it occur?
26. I HEREBY CERTIFY, That I attended the jewsmed from
خلا that w the deceased ahive on
It death is crid to have occurred on. 1/7/53
27. SIGNATURE OF PHYSICIAN
north Have
11:35 A' P. Taylor ex 17/23
wem VS-
New Haven
New Haven
Winthrop
{Middle)
15. BIRTHPLACE New York
State or f re country)
INTERVAL BETWEEN ONSET AND DEATH
quanto
RECEIVES
.!
TUR
,1
7
6
THRE
FEB13 AM
"This copy of Certificate received
for record at this day of
Registrar"
-
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 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 after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
Y
PLACE OF DEATH
Danvers
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Danvers
(City or town making return)
14
J(If death occurred in a hospital or institution, ...... St. [ give its NAME instead of street and number)
2 FULL NAME Hilda Jackson (If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. 253 Shirley ...... ............
St. Finthr (ff honresident) give city or town and State)
Length of stay: In place of death .years ... 1. .... months1.2. ... days. In place of residence .years. .months. .days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Ferale
Negro
11 SINGLE
MARRIED
WIDOWED
or DIVORCEDSin -le
4I 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.)
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AGE 46 Years
Months ...
...... Days
If under 24 hours
Hours ......
Minutes
14 Usual
Occupation :
Hotel worker
(Kind of work done during most of working life)
15 Industry or Business:
16 Social Security No.
17 BIRTHPLACE (City) ..
(State or country)
N.S., Canada
18 NAME OF
FATHER
John Jackson
19 BIRTHPLACE OF
FATHER (City)
(State or country)
N.S. , Canada
20 MAIDEN NAME
OF MOTHER
Cannot be learned
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
N. S., Canada
22 Informant ....... (Address) . Sheeh an
A TRUE COPY.
ATTEST:
{Registrar of City or Town where death occurred)
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