USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 8
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(Signed)
M. D.
MYRON N. KING M.D
(PRINT OR TYPE SIGNATURE)
(Address) 222 PLEASANT 57 Date. 2/6 60
.19
PARENTS
10a If married, widowed, or divorced
HUSBAND of
CEDAR
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Due To
NEPHRO-SCLEROSIS AND
(b)
MARKEDLY HYPERTROPHIED PROSTATE
to ...
2/6
That I attended deceased from
1960
(Month)
(Day)
PHYSICIAN - IMPORTANT No f(Was deceased a U. S. War Veteran, [if so specify WAR)
(Usual place of abode)
Winthrop Community Hospital
No.
RI R-301A 1
S
M-59-925686
-
WINT
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
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 un- related 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 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 occu- pation, 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 impor- tant, 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. Chil- dren 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.
·
FEB -31960 /"
R-301A 1
STUCTIONS :OR AI CERTIFICATE
Irgiving E)F DEATH
it enter rthan one s for each ), b) and (c)
es not mean Or of dying, s Heart failure, I, tc. It means €6, or compli- which caused
itus, if any, i've rise to huse (a), g he under- huse last.
naions contrib- o tath but not tithe terminal c dition given
- hapter 137, 54. requires ia to print or th
cause or death on :el ficates, and .r 8, Acts of "etires Physi- o int or type iner signature.
6 Holy Cross
Malden
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
February
.9,
1960
7 NAME OF
FUNERAL DIRECTOR
Porcella Funeral Service
ADDRESS
876 Winthrop Ave. Revere
Received and filed
FEB 8 - 1960
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Single
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE ....
Years.
Months.
.Days
If under 24 hours
Hours ... 4Q .... Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
None
16 BIRTHPLACE (City)
(State or country)
Mass.
17 NAME OF
FATHER
Albert A. Balboni
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country)
Mass.
11
19 MAIDEN NAME
OF MOTHER
Lorraine Paziano
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass.
21 Albert A Balboni
Informant (Address)
7 Belle Isle Ave., Revere, Mass.
I ILEREBY CERTIFY that a satisfactory standard certificate of death wa/filed with me BEFORE the burial or transit permit was issued: Galble E. Pereaning.f (Signature of Ageny/of)Board of Health or other)
2/9/60
(Date of Issue of Permit)
X
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
FEB
8
1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
FEB 8 1960
to ..
FEB
8
19
60
I last saw h& Malive on
Feb
8
19 60 death is said to
have occurred on the date stated above, at
5.10 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Premature birth
Due To Premature Separation of (b)
6 Hrs
Placenta
Due To
Placenta Previa
(c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
Clinical Exam
5 Was disease or injury in any way related to occupation of deceased: / 10] If so, specify
(Signed)
John 7 Collin M. D.
John F. Collins
MO
(PRINT OR TYPE SIGNATURE) Revere Mass Date.
8 Feb 19. 60
(Address)
PLACE OF DEATH
7 Suffolk (County ) Winthrop (City or Town) Winthrop
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
2. VE De filed for burial permit with Board of Health or its Agent.
STANDARD
32
Registered No. CERTIFICATE OF DEATH Community Has Ps §(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
No.
Baby Boy
Balboni
PHYSICIAN - IMPORTANT f(Was deceased a ¿U. S. War Veteran, [if so specify WAR) NO
(a) Residence. No.
7 Belle Isle Ave
St.
Revere
(Usual place of abode) 40 Minutes
(If nonresident, give city or town and State)
Length of stay: In place of death .. .. years .... months days. In place of residence. ............. years ........ . .. months ... .days.
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
3.27.61
PARENTS
(Official Designation)
4- 19-925686
L. C
INTERVAL
BETWEEN
ONSET AND
DEATH
40 Min
Winthrop
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
1
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 un- related 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 physicien 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 occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
91960 11
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 impor - tant, 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. Chil- dren 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.
1
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.
33.
(If death occurred in a hospital or institution, St. [give its NAME instead of street and number)
2 FULL NAME
Grace D (Cooper) Johnston
(If deceased is a married, widowed or divorced woman, give also maiden name.)
58 Thornton Park
St.
(If nonresident, give city or town and State)
Length of stay: In place of death.
years
7
months.
days. In place of residence
30 years
months ....
_ days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
teh
10
1960
(Year)
(Month)
(Day)
4 I HEREBY CERTIFY,
That I attended deceased from
7-3
1991
to.
2-10
60
I last saw h Evalive on
1-eb. 6, 1960, death is said to
have occurred on the date stated above, at
7.45 A.m.
INTERVAL BETWEEN ONSET AND DEATH min.
11 IF STILLBORN, enter that fact here.
12
78
AGE
Years.
C
If under 24 hours
... Hours ...... Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own home
15 Social Security No .. 012-18-511-
16 BIRTHPLACE (City)
(State or country) , et.
Brunswick
17 NAME OF
FATHER
William Cooper
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER mary Palmer
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
21
Informant
Roy I. Johnston
(Address)
58 Thornton Park
inthron
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS
inthron laws
12, 1960
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED . 1dow
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Joseph Johnston
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cerebro Vascular
hemorrhage-massive
- (b) Due To ce averiosclerosi5 generalized
Due To
Senilità
(c)
OTHER
Parkinson's Disease.
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? If so, specity
Joseph Gregorie
(Signed) napoli Vier
M. D.
(Address).
5) 199 Washington de5 Date 2-10
60
19
6 Winthrop
Winthrop
Place of Burial or Cremation
DATE OF BURIAL
(City or Town) Feb. 13
1960
50M-1-58-921876
PLACE OF DEATH
RIR-301A 1
12
S UCTIONS FOR A CERTIFICATE
Ingiving EOF DEATH
It enter re:han one s for each ), b) and (c)
s ves not mean 01 of dying, s heart failure, d, 'c. It means es. or compli- hich caused
itis, if any, ve rise to ause (a). the under- last.
dans contrib -- > o ath but not tithe terminal c dition given
Chapter 137, £ 54, requires ia. to print or th
cause or death ce lficates.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burjal or transit permit was issued: Maxi a ( tereanne, & ! (Signature of Agent of Board of Health or other)
2/12/60
(Official Designation) (Date of Issue of Permit)
V. 4.
V :
To be filled for burial permit with Board of Health or its Agent.
Bayview Nursing Home No.
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, if so specify WAR)
(a) Residence.
No.
(Usual place of abode)
Received and filed
PARENTS
4
Months
Days
it John
-1
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, 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 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 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 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 deccased 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 examination upon the view of the dead bodies of persons as are 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 issuc 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 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 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 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
RM R-302
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 resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
×
PLACE OF DEATH
Middlesex (County )
Medford
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Medford
(City or Town making this return)
Registered No.
34
§ (If death occurred in a hospital or institution, .St. { give its NAME instead of street and number )
2 FULL NAME.
Nettie M. R. (Conohan) Magee
( If deceased is a married, widowed or divorced woman, give also maiden name.)
36 Atlantic
St
Winthrop
(a) Residence.
No.
( Usual place of abode)
1
50
days. In place of residence
.. years ......
.months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February
12
1960
(Month)
(Day)
(Year)
8 SEX
female
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
widow
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ...
Frank P.Magee
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
1
AGE
Years
Months
Davs
If under 24 hours
Hours .......
Minutes
13 Usual
Occupation :
Housewife
( Kind of work done during most of working life)
14 Industry
or Business :
Own home
15 Social Security No.
011-01-3743
16 BIRTHPLACE (City)
(State or country)
Prince Edward Island
17 NAME OF
FATHER
John Conohan
18 BIRTHPLACE OF
FATHER (City)
Prince Edward Island
(State or country)
19 MAIDEN NAMEelvina Aitken OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
Prince Edward Island
(State or country)
Paul D. Magee
8.York Rd.,
Manchester
A TRUE COPY
ATTEST :
0
( Registrar of City or Town where death occurred)
DATE FILED
Feb(15, 1960
19
V.B.
( Registrar of City or Town where deceased resided )
PARENTS
Alfred C.Mucci
(Signed)
420 Broadway
M. D.
(Address )
Somerville.
Date.
2/ 12
60
19
Winthrop
Winthrop
6
Place of Burial or Cremation
Feb 15, 1960
19
(City or Town)
DATE OF BURIAL
Howard S. Reynolds
7 NAME OF
FUNERAL DIRECTOR
Winthrop, Mass.
ADDRESS
Received and filed MAR @ 1960 19
PERSONAL AND STATISTICAL PARTICULARS
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Bronchopneumonia
INTERVAL
BETWEEN
ONSET AND
DEATH
1dy
Due
(b)
Chronic Cardiac
Decompensation
yrs
Due To .. (c) A terial Hypertension
yrs
OTHER
SIGNIFICANT
CONDITIONS.
Was autopsy performed ?
no
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
no
1
..
M. S .
50M-9-59-926111
That I
attended deceased from
4 I HEREBY CERTIFY.
Dec
31
19 59
Feb
12
60
I last sawer
.... alive on
2.20A
to .....
Feb
II
19
1960
death is said to
have occurred on the date stated above, at
.. m.
( Was deceased a
U. S. War Veteran,
(if so specify WAR,.
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years ..
months.
15
Emery Nursing Home No ..
21
Informant
(Address)
76
4
MAR -21900 14
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
AR-301A 1
PLACE OF DEATH
Suffolk (County)
HÉLÈNE
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
35
[(If death occurred in a hospital or institution, St. [give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
( if so specify WAR)
No
(Usual place of abode)
Length of stay: In place of death.
.. years
months
12
days. In place of residence
147 years.
months.
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
teb
(Month)
(Day)
14
1960
(Year)
A I HEREBY CERTIFY,
DEC 4
That I attended deceased from
1954, to FEbil
60
I last saw h /2alive on
FED4, 1966, death is said to
have occurred on the date stated above, at
-11,36-A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
PULMONARY EdeNA
(a)
Due To
CORIN'ARY GECLUSICH
(b)
Due To
HYPERTENSIVE
(c)
HEART DISCHISE
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis
CLINICAL
5 Was disease or injury in any way related to occupation of deceased? // If so, specify
(Signed).
(Addr
6 Glenwood Place of Burial or Cremation
Everett
(City or Town)
Feb 16, 1960
DATE OF BURIAL
7 NAME OF
Purcella Funeral Service
ADDRESS 876 Winthrop Aver Revere
Received and filed FED 15-1960 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
White
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
Or DIVORCED Widow-
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
James Fitzpatrick
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGE
12
55 Years.
7
Months
12 Days
If under 24 hours
Hours ....... Minutes
13 Usual
Occupation :
A7
HimE
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No. None
16 BIRTHPLACE (City)
(State or country)
Canada
17 NAME OF
FATHER
John Conrad
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Canada
19 MAIDEN NAME
OF MOTHER
Emiline Knickle
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
21
Informant ....
Margaret Smith
(Address) 109 Endientt Avec Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death was fled with me BEFORE the burial pr transit permit was issued:
(Signature of Agent of Board of Health or other)
DeleteOfficer 2/5/40 (Official Designation) (Date of Issue of Permit) X
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