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181244
UNITED STATES OF AMERICA
CERTIFICATE OF DEATH
FROM THE RECORDS OF DEATHS IN THE CITY OF GLOIJCESTEB,
MASSACHUSETTS, U.S.A.
1. Date of Deatlt - - -
2 Name - - - -
(Maiden Name) - - -
3. Ses, and whether Single, -
Married or Widowed - -
4. Name of Husband or Wife
6. Color - - - - -
6. Age - - - - -
7. Disease or Cause of Death -
8. Place of Death - - -
9. llesidenoe - - - -
10. Occupation - - - -
11. Plsce of Birth - - -
12 Name of Father - - -
13. Birthplace of Father - -
14. Maiden Name of Mother -
16. Birthplace of Mother - -
16. Place of Interment -
Aiav 1,19b6 FfLEO~ AN0 RECpRD~'~
E~ pRnCVeERIFII~E-D~~
Henr Simmons
irtale ~ ~~~- '
l~iarri e d C-f~-~9+~~~
Helen J. Saari CLERK CIRCUIT COURT]
White
fib yes 9 months 29 nays
Oat Ce
er
sloucester idass.
Business Administrator
ico. Azore
~~Testern Islands
Calvary ___ ___
I. Fred 3. Kyrouz
depose. sad _say that I hold the
office of Cty Clerk of the City of Gloucester. County of Essex, and Co~nrgpiiMth ,s>1 Massachusetts;
that the raords of Births, Marriages and Deaths required by law to he kept.-i~t ire in my custody.
and that the shove is a true copy from the records of Deaths in said City.-asb~ek~td
•~ ..
Wrrrtt:ss my hand and the sal of said City. on tliT ,;,: r. ~+.= h
x.
day of May r. ; -- ~ .
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soflK 17y ~~ 1y7
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