HomeMy WebLinkAbout1523 `1 215464 ~i~?~ c~,~~~~~~~~~~~~~~~~.~~,i~ ~~t ~~titltiliiltl~lllil'~~~~ ,~i
, L~`,~~ ~j ~ . JOHN F. X. ~AVOREN t.rOT`CC,^,tC2^ . _ . ~
~ ~,n~~ y ~ BECRETARY OF YHE COMMONWEALTM ~
~i +e :•ORC' ~up~~-- ~ ~IVIYION QF VITAL BTATISTIC6 1(~~r ur Tur~ walins t6is retYt~) ~
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I~ ~ ...___;.`O:tC'~T:.R. . ~ STAN~ARD ~
C ERTI F! CATE O F D EATH ~~rsiuercd No. ~
J lCits or Tura)
~ J U( dealh occurreJ in a h.auiul or iauitutiw. ~
. ,
~ i~to. AIIIdi2It1t1N..'~IOSPIi1lL. . s~. t . '
.~~~~1 x--301 . . . un iu !A\1F. instesd ot ~treet aod nu~bec) ~
t:1:1 for burial pecmit P Y( (~dee~wsa~1L;PORTANC
:
,,~.ra or u~.~~ ' s tcu. x~~~e ._~~u2'~iA S P:'L~iSOII .......(Svenson) w~
- C. S. •r 'eteras. '
.,r iu A~ed. lI( deceaxJ is a oarricd, ridureJ or dirunrd ~ri.maa. ~i+e also saidea eame.)
speci(y \YAR) _ _ .
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: ~,TAl'C'TIO\S - n - . r ' ~ ~~vp 1
F JR (a) Permanent Rwdrnte. \o. i::~':....~~ITaj.....l~Q..IL. . ; Jt. .....~aV .N~~..~ 1~;1 i'uaJ.S... .
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;i A:. CF:ATIFICATE ` (Cits or Iuwa aad Sute) ,
~ ~fEDICAL CERTIF[CA7'E OF DEATH PEASONAL AXD STATISTICAL PART1ClILARS ,
~~:~I' OK Tl'PE ~
,~'~i e~fi C.aIJSES ~ 3 UATE OF 7 7/ ~ SEX 10 COLOR 11 5I\GLE (write t6e wonf) !
uF llEATIt Dk.?TH ....~".f~ r F:..... . \tARRtED ~
(~lonthl ~DaY) (Yeu) \YIDOWED~ti'1~n~JQC: '
4 1 H E R E B Y C E R 7' I F 1' . tLat I attended deeeascd Iroa f
e i'?a 1 e wh ite I DI VORCED ~
,i., n.~: ente[ ~ UKf~AOW\
r.:.:;~• t'~an oue C:. ~ 19:/.i.~........., W_........~j~/)j.
`....1....., 19_1.f..... 12 1( manieJ. widowed, or ~liroroed :
~l...e ior eacL 1 last saw h~'~ . alire oa ....1~'ffrl/_ 1.. , 197~. deatb is said to HUSBAND of '
f ,L'. ~bl rnd (C~ ~
ha~~e occurred on the d~te stated ~bore. at -3'". m• IIITEh/µ (Give maidrn name o( wife in (ull) ;
~•.a :i,<, .:ot .~~ow DEATfI NAS CAUS6D BY:~MfiDIATS CAUSB ~EiMEEM WIFE ~ eriel:-~H - ~;ear~~n
r.:.:i J! dI7RO• ' ~ ~ / OMSET AMO d LLS~a+~d f aam! M i{tIp
,:i t.<art 1ai:rrt. (a1~:~y'fLi~ ~!~.Xl'!~l~.. ~!//J. . C Gl,L. ~L.-.......... lp~~ 1J 7 8 ~ ~ 6 ~ IE undet 34 boun
. , r... It ~ntaw~ . ~ ~1C ACE ~
~~~a_~. o• eo+wyfi. Yeats aton Dari Houts liinutes .
~r.~a cawe! Due To !4 Usual ~;~useF.*i fe
OccvPUion '
(b) (Kind of work dooe durinR m~»t of workinK life) Z
1S Industry ~~'m nTng '
-.:::i.;n~. i! awy. Due To or Busiaess:
icre +i~e to (e) .
. ,
, , in is s~ s~.:ti ,o. ..A.3.1.-1 ~.-1.3..7.. ~
, :n. ,~*a~- ortise
cawt la~t SIG\IFICA\T
CO\'D1T[O\S ~ 1T BIRTHPLACE ( 'tr) ~
, (St~te or country) S~Te''C~@ZT i
; _ ~
v~ corctrib- N'as a~toP~Y P~ormed? i•~
, _ . . . ` _ 8 NAJf E OF
c~.::k brt not
I:i<: w c.,a tmniwal Wbat test con6rmed diaanosii7 ~~-..~~J.~' ......................._...............L FATHER Joh~nn Svenson
! :-ec condiLiowyi7A ~
' F 19 BIR'fHPLACE OF
~ i ~ S~Vu diuase or injury in ~nY way rdated to oc~vD~tion of deceasedy. FATHEN (CitY)
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u s~;rr ....w................................. x S~~~eden
~ ' (staee w caunM) ~ 3
j (Sigoaturc) (.l~.~.~i::_ . ~..Ls.?J~~ 1[. D ~ YO MAIDEN NA~fE . . '
~ ...............f~.~.':~.~ik.:.7.......:..<..~~~:~~~1.~......... ~ OF 1t07'HER cizlda C. Johanson ~
~ lPri~t a~ ?1De Naiwe)
,
~ - , ~ • - 0. 41 BIHTHPLACE OF (
(Address) . .L~--a.:.V..:.:......~~.._ Date ......,1..
f....,f.. 19..~./..
At0'fHER (City)
r es~~« a~~.r~ c•. e C~e n ~
eRurel Crer~atory_,_.._.__~~lorceste._ f r.
Place of B~~wl or Cremation (Catr or Town) I HER RTIFY ~ a sa f ory staadard cestifit te of de t6
I DATE OF BURIAL ?'I.dy ..4.~ . 19?~. was 6 .ri me 9~F¢RE the a~ or vysir~sro~R~.cos~' ~ y'~ (
,,,,.;.~f
~ i ._c..-..:........... Rl~...~ i
7\A~fE OF , . . fSni~?ature of A~eat Board~of Hea~tL or otLer) '
? ~c;`ERw~,D~~czoRArthur...R.....1~rdpren....,.__.... .
f / . . . :
1 300 Lincoln St. ~~orcester . . f.a~..l.. .
ADDRESS ~(O~cral Desigaat~oa) . (Datr ~~ue of Permit) :
~
• _ o ~ra~ss:oncr of Pub;ic Hea •
. d io........ 4;
I s Mr.s......11.L.f~ed....H.r~-~-~l~a-s~tb~erp ~~7~~=; ~ , ~ ,
~ <waa.~.~ -.Tw~i....,~i11....Rd...,Iiuhbar.dston•,• . . ~:wlv"f'".`'1''-_~./l ' ~~:i
.,.-::•or•o~57i3 1 . ..A TAUB OOPY A~
Mass. ~ O
Fi~EO Ati4 RECOROeo ~
s7_ wciE couNtr F~~.
iiOCE~ POITRAS ~ .
CLERK C~~CUIT COURT
r RECOaD vEa~F~ED '
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~ S~ 13 10 oi AN'll ~Citp of ~orce~ter
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4 CITY CLERK'DEP.ARTrtENT N`:::_' .23271
~ ~15~6 ;
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The above is a crue copy of the original certificate placed on file i~'~;~`; .
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1 ,t
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office, and issued this date: ~Y 6 191~ - ~ w:'''~ .
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A Copy. Attett: ~ -
. • Thomas`F, :1?onabu~ =
- d0~ 195 ~ 152~ ASS~t Clt~'~' r.r '
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