USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 3
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Health Oficir
Jan 25. 176 3
(Official Designation)
(Date of Issue of P'ermit)
TX
1
2 FULL NAME
Florence A (Noyes) Brown
(If deceased is a married, widowed or divorced woman, give also maiden name.)
66 Winthrop Shore Drive
St.
18
(If nonresident, give city or town and State)
RUCTIONS FOR CERTIFICATE giving OF DEATH not enter than one : for each (b) and (c)
does not mean le of dying, heart failure, etc. It means se, or compli- which caused
ons, if any, gave rise to cause (a), the under- cause last.
tions contrib- - death but not o the terminal ondition given
Chapter 137, 1954, requires ns to print or le cause or of death on
ertificates. . C.
SOM-5-56-917573
PLACE OF DEATH
R-301A 1
PARENTS
Jan. 25
5
Crest Haven Rest Home No.
Registered No.
Jefferson
-
(b)
Disease
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registercd 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 seventecn. 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 sclectmen 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 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 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 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 «selang 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
1
2 FULL NAME
Jeanette Loessl Johnston
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Address- 149 Wasting Ton AVE
P20 - 3rd Floor Fort Banks
.... St .. Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months.
3
.days. In place of residence.
4.
years ..
... months ....
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
1
25
1963
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from Jan 22 63 19 19 63
to ... Jan 25
I last saw h ...... alive on
Jan 75
19 63 death is said to
have occurred on the date stated above, at
10:15Pm.
INTERVAL BETWEEN ONSET AND DEATH
Du
(b)
TRheumatic heart disease
Due To (c)
OTHER
Subacute Bacterial
SIGNIFICANT endocarditis cérébral
CONDITIONS
emboli
Was autopsy performed?
NU
What test confirmed diagnosis? Ecq x Rays Blood Studies
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
No
(Signature)
Hoslaven field
M. D.
H. B Greenfield
(Print or_ Type Name)
1-26
1963
Forest Hills Crematory Eoston
6
Place of Burial or Cremation
(City or Towuass.
DATE OF BURIAL
January
28,
1963
7 NAME OF
FUNERAL DIRECTOR
J.S.Waterman & Sons
ADDRESS
Foston , Mass.
Received and filed
JAN 28-1963
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCEDDivorced
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Charles M. Johnston
(Husband's name in full)
12
AGE
.4.6 ears ...
5.
.Months ..... 2.4Days
If under 24 hours
Hours ..
.. Minutes
13 Usual
Librarian
Occupation :
(Kind of work done during most working life)
14 Industry
or Business:
Fort Banks , Winthrop, Mass.
15 Social Security No ....
156-10-5917
16 BIRTHPLACE (City) .. Boston.
(State or country)
Mass
17 NAME OF
FATHER
Cannot be learned Loessl
PARENTS
18 BIRTHPLACE OF
Munich
FATHER (City)
(State or country) Germany
19 MAIDEN NAME
OF MOTHER
Fertha Petrol
20 BIRTHPLACE OF
MOTHER (City)
Sulseld
(State or country) Germanv
21 Informant
Charles Snyder
(Address)
10 Riverdale Rd. ,Concord, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Call 6.
(Signature of Agent of Board of Health or other)
Healthother
un 26. 1103
(Date of Issue of Permit)
62-932382
X
PLACE OF DEATH
Suffolk (County)
1
Winthrop
(City or Town)
Winthrop Community Hospital No.
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
12
Registered No.
S(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
(a) Residence. No.
(Usual place of abode)
OR TYPE OR CAUSES DEATH not enter : than one e for each (b) and (c)
laes not mean de af dying, heart failure, etc. It means se, or campli- which caused
ions, if any, gave rise ta cause (a), the under- cause last.
ditians contrib- death but nat a the terminal ;andition given
......
(Registrar) || (Official Designation)
A TRUE COPY ATTEST:
ORM R-301. 536.4119
for burial permit ard of Health ts Agent. RUCTIONS FOR CERTIFICATE -
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Pulmonary embolism
3 7 days
(Address)
447 Shirley St
Date
with
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.
5M-6-60-928241
Suffolk (County ) PLACE OF DELIVERY No. Winthrop Community Hospital
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)
To be filed for burial permit with Board of Health or its Agent.
Registered No.
13
(If death occurred in a hospital or institution, give its NAME instead of street and number)
3 DATE OF
DELIVERY
1
26
1963
(Year)
( Month
(Day)
7 IF MULTIPLE BIRTH, BORN :
1st.
FATHER
8
FULL
NAME
Herbert Miller
14
MAIDEN NAME
Teresa Joyce
Teresa Miller
RESIDENCE, NO.192 Constitution AveSTREET
CITY OR TOWN
Revere
.STATE .. Mass .
RESIDENCE, 192 Constitution AveSTREET Revere
CITY OR TOWN
STATE. Mas.s ...
10 COLOR OR
RACE.
Wh .
11 AGE AT TIME OF
THIS DELIVERY
38 .. (Years)
16 COLOR OR RACE Wh
17 AGE AT TIME OF
THIS DELIVERY
32 (Years)
12 PLACE OF
BIRTH
Chelsea
(City or Town)
Mass.
(State or country )
18 PLACE OF BIRTH Roxbury
Mass .
(City or Town)
(State or country }
13
OCCUPATION
Laborer
19 INFORMANT
Herbert Miller
20 PREVIOUS DELIVERIES TO MOTHER (Do not include this fetus)
2
(a) How many children are
now living?
2
(b) How many children were born alive but are now dead ? 0
(c) How many previous fetal deaths of ANY gestation age ? 0
21 LENGTH OF PREGNANCY 8completed weeks
22 WEIGHT OF FETUS
Lb
15 Oz
23 WHEN DID FETUS DIE? Before Labor
During Labor or Delivery Unknown
25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Due To (b) Due To (c)
OTHER SIGNIFICANT CONDITIONS
26
Holy Cross Cem. malden 1face of Burtal or Creniati
( City of Town )
DATE OF FURIAL
27
NAME OF
FUNERAL DIRECTOR
Paul Buonfiglio"
ADDRESS 128 Bever St Lavere
Received and filed
JAN 29 1963
19
I HEREBY CERTIFY that this delivery occurred on the date stated above at 4.12 Am., and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner : Myron b. King MYRON NI KING M.D (PRINT OR TYPE SIGNATURE) Date 222 PLEASANT ST. L'INTEROP 5L MIDAS
M.D.
1/28 63
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued :
.
Signature of Agent of Board of Health or other )
Health officer ( Official Désignation i
xan. 28.19 6-3 (Date of Issue of Permit )
A TRUE COPY ATTEST :
RM R-304
1 Winthrop (City or Town)
2 NAME OF FETUS
(if given)
Baby Boy Miller
4 SEX
Male MFemale .. .. Undetermined .. ..
5 COLOR (if
determined)
W
6 THIS BIRTH (Check one)
Single A Twin
Triplet
.2nd .3rd.
In giving CAUSE OF TAL DEATH
do not enter nore than one ause for each of (a), (b) and (c)
tal or maternal dition causing al death (do t use such ms as stillbirth prematurity. ) tal and/or ma- nal conditions, ny, which gave se to above se (a), stating e underlying use last.
nditions of fetus mother which y have contrib- ed to fetal ath, but, in so r as is known, re not related cause given (a ).
January
1943
24 AUTOPSY
Yes
No 2/
For
Grams )
Registrar
St.
MOTHER
PRESENT NAME
FETAL DEATH
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48. ACTS OF 1960.
Section 2A. "Examination of records and returns of illegitimate births, or abnormal sex births, or fetal deaths, . . . shall not be permitted.except ... ".
Section 9A. When a child is born dead, after a period of gestation of not less than twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and no movement of voluntary muscle, the/physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.
Section 12. “. . . No birth record of a child born out of wedlock or of a child of abnormal sex, and no record of fetal death shall so be transmitted to any other city or town."
Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.
FORM R-301
for burial permit oard of Health its Agent. TRUCTIONS FOR L CERTIFICATE
T OR TYPE OR CAUSES · DEATH not enter e than one se for each , (b) and (c)
does not mean ode of dying, heart failure, , etc. It means case, or compli- which caused
tions, if any, gave rise to cause (a), & the under- cause last.
nditions contrib- o death but not to the terminal condition given
C.
PLACE OF DEATH
X Sulfack (County) 1 Wynikion (City or Towg) 56 Cheater ofranz
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
Registered No. 14
f(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)
NOT. 56 Cheater Chez
(a) Residence. No. (Usual place of abode)
St
(If nonresident, give city or town and State)
Length of stay: In place of death. 7 years~months ......... days. In place of residence { years: months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
mac
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Eisenberg
(write the word)
Manual
11 If married, widowed, Or divorced HUSBAND of
(Giye maiden name of wife in full)
INTERVAL
BETWEEN
ONSET AND
(or) WIFE of
12
AGES !
DEATH
15MIN
Years
-
.. Months.
Days
(Husband's name in full)
If under 24 hours
Hours ......
Minutes
13 Usual
Occupation :
4(Kind of work done during most working life)
14 Industry
or Business;
DE Nuclear Corp
15 Social Security No. 013-05-3942
16 BIRTHPLACE (City)
(State or country)
Boston Har
17 NAME OF
FATHER
Harris Rondon
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ruiva
19 MAIDEN NAME
OF MOTHER
Rosi mirch's
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21 Informant
( Address)
Mothertest Deunteren
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
fériasice
(Signature of Agent of Board of Health or other) Health infec
PilLO . 2% 111.5
(Official Designation)
(Date of Issue of Permit)
TVIV
A TRUE COPY ATTEST:
3 DATE OF
JAN
27
1963
DEATH
(Year)
(Month)
(Day)
4 I HEREBY CERTIFY. That I attended deceased from
MAY 14
1957
to ....
JAN 27
19.63
I last saw h.illive on
JAN 27, 196, death is said to
have occurred on the date stated above, at
12=P
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ACUTE MYOCARDIAL INFARCTION
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
No
What test confirmed diagnosis ?
CLINICAL
5 Was disease or injury in any way related to occupation of deceased No. If so, specify
(Signature) myson h Ruiz M. D. MYRININ KING- M.D
222 PLE (Print or Type Name)
(Address) WINTHRO
JANT SI 1/27 63 19 Date ...
Comments for
Place of Burial or Cremati
Jan 28
(City or Town)
7 NAME OF
FUNERAL DIRECTOR
ADDRESS Chelsea
Received and filed
JAN 28-1963
19
(Registrar)|
-62-932382
No.
Harry London
2 FULL NAME ..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
JURISDICTION
MEDICAL EXAMINER DECLINED
PARENTS
Inez- Lonalon
DATE OF BURIAL
NONE
Supin
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
i
0
THE
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance Alm2 31963 PM following rules of practice : 1
(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 froin 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.
PLACE OF DEATH
Suffolk
(County)
ENSE
Winthrop
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD 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. 15
f(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Sophia Rosenauer
(First Name)
(Middle Name)
(Last Name)
[(Was deceased a
U. S. War Veteran,
[if so specify WAR)
no
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death.
.years.
months.
days. In place of residence.
years.
.. months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF jan
DEATH
27
63
(Month)
(Day)
(Year)
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDTid owed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
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