The volume, 1960
Town Clerk, Winthrop · from the Internet Archive · 594 pages · 37.8 MB
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..Suffolk
(County) ,
VTf
..Wln.tlir.o.p
(City or Town)
ltC>)e CommontDealti) of iHaooacljuoettc
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No
((If death occurred in a hospital or institution,
No. Wlnthr.op C.02mjiunl.t.y....Hoa..pi.tal St. ( give its NAME instead of street and number)
4*1’
[if SO :
2 FULL NAME .. jaSEPlI.,.,. mRGU.C.C.IIXI...,.C.AKA... Jp.seph,..Mar
\Var Veteran, WrN
specify WAR)
(a) Residence. No. 419.....Mer.idlaii....S.t.,.., BQS.t.on st Ea§..t,,,.Bpstpn
(Usual place of abode) (If nonresident, give city or town and State)
..5 days. In place of residence..3.d...
Length of stay : In place of death years months..
..days. In place of residence . J.Srt... years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
' DEAT January. 1..
(Month) (Day)
19.60.
(Year)
9 SEX 10 COLOR
Male I White
41 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.)
..C..or.onar.y. o.c.cluaion f.Qll.o.w.ing .blunt
..f..Q.r.c..e. .in.Jury .of. .che.a.t with....mul.t..lp.l|^
..fra.c.tured. rlba..>
II SINGLE (write the word)
MARRIED
^yViY'v'^I^ED Widowed
HUSBANo'lf .:“Mk'i?'^li‘ferita C.auc.ci..
((<ive maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 IF STILLBORN, enter that fact here.
5 Accident, suicide, or homicide (specify) .Accidento.
Date and hour of injury 12/2.7. 19.... 59
IF ACCIDENTAL, was injury causally related to the death?
..Boa.ton.^ Maas..,
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in
public place? Home...
(SpcciTj
aV,e.....8.3
Years .^..Months.
12
Days
If under 24 hours
Hours Minutes
Real .Estate Retired,
Occupation:
Where did
Injury occur?
(Kind of work done during most of working life)
IS Industry
or Business:
16 Social Security No.
Real Estate
[removed]
(Specify type of place)
Manner of i i. •
Injury Slipuad Oil s.ta.irs..*..
THow did injury occur?)
17 BIRTHPLACE (City)
(State or country)
Nature of
Injury
While at work ? Was autopsy performed ? .No.
M. D
..Ml.feha.e.l.,.A.. Luong.o.«
(Print or Type Signa^rej . \
(Address) ..3.0a..t.0n.< Ivlaa.a Date ....l/l 19....6..C
Italy
18 NAME OF
FATHER
Francis Marcuccilli
19 BIRTHPLACE OF
FATHFR rritv'l
(State or country)
Italy
20 MAIDEN NAME
OF MOTHER
Rose Rea
'
21 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Italy-
3..t« Michael...'.s Ceraete.ry, .Boston
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL .J.an.ua.ry......4th i9.....6(|
22
informanMr.^ Ja.mss V. Marc.ucella^s on..
(Address)^!^ Moridiaii Qt., IS. Boston
BY lERTIFY that- a satisfactory sfaruiard certificate of c
* FUNERAL DiRECTORE.i.chard ,C • Kirby. j ,I.nc *
ADDRESS 9.1.7......Be..nn.i..ng.t.o.n.....St.»..., .E,BQs.t.Q.ri
I HEREBY (Certify that, a satrsfactory' s?atyiard certificate of death
w^ filed with me BEFORE tfie burial or transit permit was issued:
-T ;
Received and filed
JkN4 1S60
(Registrar)
(Official Designatioii)
_ ___ ... . jjr....,.— iul
(Signature of Agent of Board of Health or other)
(Date of Issue of Permit).
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE ^ -^ 7-,:,
The fulfillment of the pui'pose 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 luive 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 inj[ury, The^ include not only
deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the-’ action of chemical
(drugs or poison) 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
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under
cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with
the circumstances when these are known. For example: “Compound fi-acture of the femur with ensuing septicemia
(gas bacillus) caused by a collision of railroad train and automobile.” “Pistol shot wound of the chest with associated
hemorrhage, homicidal.” “Asphyxiation by suspension, suicidal.” “Syncope while under the influence of ether administered
as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery).” “Fracture of the skull
with associated internal injury sustained under circumstances unknown.”
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease,
specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to
medico-legal inquiry. For example: “Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed).”
“Heart disease, presumably coronary sclerosis. (Sudden death.)” - .
t. • • \
R-305
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a-«60
4l 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.)
Cagonary. .Hieagt Dlaeaae
Sudden ,.DQ.atJi -
/I
I ^
u ...Xd.ddX.e.s.e.x
“ (County)
O
uj
U (City or Town)
J
ft. No,
^i|e Commonfoealti) of (Masoactfusetts
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
■ Canib.p.i.df?e
(City or town tliaking return)
Registered No.
19
2
2 FULL NAME,.
^ I. O T ol^A AW AwAmiTA occurred in a hospital or institution,
.. JLf A™. St. ( give its NAME instead of street and number)
lu^S* War^Veteran,
(if deceaseii is a married, widowed or divorced woman, give also maiden name.)
(if so specify WAR)
Ho
(a) Residence. No. .95 C.o.urt; Hoad st. ...W.l.n.tl:mQ.p.^ Mas.3.ac.bua.e..t.t.a..
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay : In place of death years months l..days. In place of residence ij...years months days.
MEDICAL CERTIFICATE OF DEATH
DEATH*™... .J!..aniiapy 3a. 19^
(Month) fDay)
(Year)
9 SEX
10 COLOR
11
1
S Accident, suicide, or homicide (specify)
Date and hour of injury 19..
If accidental, was injury causally related to the death ?
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 ?
Manner of
(How did injury occur?)
(Specify type of place)
Injury
Nature of
Injury
While at work? Was autopsy performed? JM.
6 Was disease or injury in any way related to occupation of deceased No
If so, specify
(Signed) Da*i.d....,G.*....Bow. M.
(Address) .DatdJaHi Ju.,,6a
, .C.RiGferidsft..,,£«a» Cssbcldfi-fl..
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL
JjMmagy.....7teli..
i6*o..
* FUNERAL DIRECTOR Richard C.a Klrb.y.
ADDRESS 9-X7.,...B(Bll>0.1]Pg.1tf.0.CT......8.1!?..«.E..*.JU.3.S
Received and filed ...j, ,..,r.
nt-
(Register of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
!^!l^elen-..Karce-Xla..
(write the word)
MARRIED
WIDOWED ^
^ivoRCEDBarriod
11a If married, widowed, or dijtprcg
HUSBAND of : _
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 IF STILLBORN, enter that fact here.
AG E.^^.... Years... 6 Months..l^..Days
If under 24 hours
Hours Minutes
14 Usual
(Occupation:
(Kind of work done dun
uring most of working life)
IS Industry
or Business:
16 Social Security No.
.Q2iLM>QSji»?61ij0l
17 BIRTHPLACE (City)
(State or country)
18 NAME OF
FATHER
Italy
t Pater MpIo
19 BIRTHPLACE OF
FATHER (City) ....
(State or country)
Italy-
20 MAIDEN NAME
OF MOTHER
21 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Calapa
Italy
Informant
(Address) Qtt GOlirt ^ , -
A TRUE COPY.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED 19.
.Jan. i.,..
6o
/
/
J
t
i
/
/
(
<
i
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
• V »
FEB - A I960
:M R-301A
STRUCTIONS
FOR
»L CERTIFICATE
[n giving
E OF DEATH
I not enter
re than one
ise for each
), (b) and (c)
does not mean
ode oj dying,
s heart lailure,
1, etc. It means
ease, or compli- ^
which caused
itions, ij any,
h gave rise to
! cause (a),
ig the under-
cause last.
nditions contrib-
0 death but not
to the terminal
condition given
Chapter 137,
f 1954. requires
:ians to print or
the cause or
of death on
certificates, and
cr 48, Acts of
requires Physi-
to print or type
jnder signature.
M-6-S9-925686
s
( k
I (ffountv)
U I vv, c /p
(City or Towi
Qlijp Olntmnnnuiraltlj nf ilaafiarijUHPltfl
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.
vv^iiy ur lowiv \ i \ t “
I I ok L O'H tlv f(If death occurred in a hospital
No. r. X |x. St. j give its NAME instead of stree
, Ann Louise (Stathara) Albee physician —
Registered No.
,3
or institution,
street and number)
2 FULL NAME..
— (stathara) jLLuec physician — important
4- (-be e-
(If deceased is a married, widowed or divorced woman, give also maiden name.)
|4
[if so specify WAR)
(a) Residence. No St.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years monthsf^f days. In place of residence.....^™..years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
vJcLv\ V<XvY (o 0
(Month) I (Day) (Year)
4I^EREBY CERTIFY ^That I attended deceased ^om
....^...Ql...'V(\ 19..(<I...Q, to .T,^...Vi 19..4..S?.
I last saw hS/C^live on ..X^.CL.y^. (a...z:...Lf i4..0..... ., death is said to
have occurred on the date stated above, at 3..!...3...QA.m.
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
Female
’•Vhite
WIDOWED I'Ji Hqw
or DIVORCEd"-'-^^'"
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)C.o..C.9..:h...?..r..^. ^4..t!.9..>^t:v...(?...0....?....!..^.
"T>r s e’cfT c
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
3) day^
N ci r
/CV) ouj>)
/V 0 I
ouj \
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased/?
If so, specify .....^
(Signed) , M. D.l
.OL::.:......x:v7..tt..H .€.-.....C.-s...i/.i..vi...^ c\.}:>..
^ (PRINT OR TYPE SIGNATUR^ ,
(Address) rv/rALAX, Date..Z....X..0!...?1 19.¥...y.
6 Mi*. Aubuym
Place of Burial or Cremation
DATE OF BURIAL .y..^.l..t......7 19.
(City or Town)
60
^ FUNeIrAL DIRECTOR hOWfLCd £. R
ADDRESS k'in.i.hrop
Received and filed ... JA+V-g I960-
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ?.fiyf.§.?.^4....?......Al.P.§..6
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 rtp 1 ■] d
AGE....r;.^...Years ±r:..Months...!::! Days
If under 24 hours
Hours Minutes
13 Usual Housewife
Occupation:
(Kind of work done during most of working life)
or Business : ...O.Mi....horae..
15 Social Security No.
..iioae...
16 BIRTHPLACE (City)
(State or country) £11^X3.110.
17 NAME OF
FATHER
George Stathara
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
■Ingland
19 MAIDEN NAME
OF MOTHER •cJ.len Scampton
20 BIRTHPLACE OF
i MOTHER (City) ....
J (State or country)
England
‘informant Paullne Smith
(Address)51~ HarSor View Ave. Linthrop
HEREBY
factory standard certificate of death
or transit permit was issued:
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 deceas^ had retired from busine^,
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.
M R-301A
iTRUCTIONS
FOR
kL CERTIFICATE
n giving
E OF DEATH
not enter
re than one
se for each
), (b) and (c)
does not mean
ode of dying,
s heart failure,
I, etc. It means
tase, or compli-
which caused
itions, if any,
I gave rise to
cause (a),
g the under-
cause last.
nditions contrib-
0 death but not
to the terminal
condition given
Chapter 137,
f 1954. requires
ians to print or
the cause or
of death on
:ertificates, and
T 48, Acts of
'cquires Phyii-
o print or type
inder signature.
d-6-59-925686
ulljp (Cornmnnuipaltl) nf fHasHarl^UHPllH
Suffolk
(County)
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.
St
((If death occurred in a hospital or institution,
. ( give its NAME instead of street and number)
jui .Wmf in* p^.
lu (City or Town)
's! No Bayriew Nursing Home
^ A T \ f ( W ss deceased s
FULL NAME .£(ina Prauces Townsend <u. s. war veteran, jjo «
(If deceaseais a marneo7 widowed or divorced woman, give also maiden name.) (if so specify WAR)
•51 Villa Avenue
4'
PHYSICIAN — IMPORTANT
f(Was deceased a
(a) Residence. No
(Usual place of abode)
.St.
(If nonresident, give city or town and State)
Length of stay: In place of death .5-. years months days. In place of residence. .37 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
M
4 1 HEREBY CERTIFY, That I attended deceased from
/Cm , ISeTJ^T... .7...
I last saw h&Mf.alive on . . . . ^ 19. .ir..a.. , death is said to|
have occurred on the date stated above, at ... ...m.
DEATH WAS CAUSED BY; IMMEDIATE CAUSE
(a)
Due
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? ^...
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
M. D.
(PRINT OR TYPE SIGNATURE)
.•Hingnam.lC.emef.eiS
of Burial or Cremation (City or Town)
laasua
Place
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Received and filed
ADDRESS . 174 Win.1jairjo.p S.t..».W.inthro.p.».
19..
JANR
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(,virjte the word)
Widowed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of Ceorge Townsend..
(Husband’s name in full)
II IF STILLBORN, enter that fact here.
12
AGE
84
Years...,
s
.Months..
..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
..Be tired. ..Teacher.
(Kind of work done during most of working life)
14 Industry
Business: .. Ihiblic School
IS Social Security No nOUC..
16 BIRTHPLACE (City) ...
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Charles Alger -
...Hingham..
Mass .
19 MAIDEN NAME
OF MOTHER Katherine
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
..Hingham
Mass..
f ^ a Avenue |!*^
t a satisfactory /standard certificate of death
the fe®al or /j»nsit permit was issued:
^.../....!j...O..
(Date of Issue oJ/Permj4) , ' k
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 phyeicians 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 physician* 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 deceaskl 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.
JAN -.^1960 1;:
M R-301A
ITRUCTIONS
FOR
kL CERTIFICATE
n giving
E OF DEATH
not enter
■e than one
se for each
I, (b) and (c)
does not mean
ode oj dying,
; heart failure,
, etc. It means
'.ase, or compli-
■which caused
tions, if any,
I gave rise to
cause (a),
g the under-
cause last.
nditions contrib-
0 death but not
to the terminal
condition given
Chapter 137,
I 1954. requires
ians to print or
the cause or
of death on
:ertihcates. and
r 48, Acts of
equires Physi-
o print or type
inder signature.
4-6-59-925686
Suffolk
(County)
Winthrop
(City or Town)
OlmnmnnuiFaltl^ of iHaoHarl^uaplta
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
No.
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
IMPORTANT
STANDARD
CERTIFICATE OF DEATH
Winthrop Comin^lty Hospital
/ , / . PHYSK
(If deceasea is a married, widowed or divorced woman, give also maiden name
35 Leyden East Boston
(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..
1YSICIAN
deceased a
Veteran,
Ilf so specify WAR)
(a) Residence. No.
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
0^7
nth)
z,
(Day)
777
rrr-
(Year)
4 U HEREBY CERTIFY
Z.H *12 , 19...<^.
That I attended deceased from
19
I iWt saw h.l.'.Pialive on J?. , K-...^...-., death is said to
have occurred on the date statea above, at ../3c.'..(P.d.
8 SEX
9 COLOR
M.7
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Atelectasis
(a)
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
I'f.} ^
■jiPRi'Nf OR TYPE SoNLi^R^
(Address) 19...^:^
M D.
Bt. Michael's
Place of Burial or Cremation
DATE OF BURIAL ...Jan.* 9.,#..
Bo^pn
(City or Town)
..19.
60
’’ FUNERAL DIRECTOR l*.?.n6.8..t .0 » CaggianO
ADDRESS ... 1^.? .Winthrop .Winthrop..
Received and filed 19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED single
or DIVORCED
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..
..Y ears Months Days
If under 24 hours
..2 Hours.. ..Minutes
13 Usual
Occupation:
(kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No
16 BIRTHPLACE (City) Wi.n.thr.Qp..
(State or country)
Magpanhusfttts
17 NAME OF
FATHER
Anthony F. Votalaro
18 BIRTHPLACE OF ^ ^ .
FATHER (City) B O S t On
(State or country) Massachusetts
19 MAIDEN NAME
OF MOTHER
Roberta Stover
20 BIRTHPLACE OF gQ^-^Qn
MOTHER (City) ,
(State or country) MaS SO ChUB 6 tt S
f. ‘
' .Anthony F , .p talar o
(Address) Leydfth St.. Boston^
EREBY CERTIFY th^ a satisfactory standard certificate of death
-• -o "EFOIWthe burial or transit permit was issued:
y,
V ^ II voigna^re of -AgeBt^ Board of Health or oAer)
.<Lr/..^..£r.
(Official Designation) // j j (Date of Issue o|/Perm)t)
✓
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 deceas^ had retired from busine^,
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.
M R-301A
,_v
TRUCTIONS
FOR
11 CERTIFICATE
n giving
J OF DEATH
not enter
e than one
se for each
, (b) and (c)
does not mean
sde oj dying,
heart failure,
, etc. It means
ase, or compli-
which caused
tions, if any,
gave rise to
cause (a),
g the under-
cause last.
sditions contrib-
1 death but not
to the terminal
condition given
Chapter 137,
1954, requires
ians to print or
the cause or
of death on
ertificates, and
r 48, Acts of
equires Physi-
0 print or type
nder signature.
1-6-59-925686
Suffolk
(County) V/ < r:\ f
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
J r '^1-^ QInmmnnuipaltl) of iJlaafiarliuaptlB
■* ' ■ ' To be filed for burial permit
with Board of Health
or its Agent.
1° jagt Bogton
JU (City or Town) Winthro_
\ J T.T • .._ 1 n • TT • 1 I (If death occurred in a hospital or institution,
0- No. ...V» in t-hlT.O P- ■•■•C OrnniUIli t y rlOS.p iXi&i. - St. ( give its name instead of street and number)
PHYSICIAN — IMPORTANT
1 FULL NAME |(W|.
(If deceased is a married, widowed or divorced woman, give also maiden name.) [if so specify WAR)
STANDARD
CERTIFICATE OF DEATH
Registered No.
6
no
(a) Residence. No 5..2.4 ....S^Her ...S.U East Bcston., I^ss.,..
(Usual place of abode)
(If nonresident, give citj' or town and State)
Length of stay: In place of death years months l..:^..days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF January 9
DEATH
T9^
(Month)
(Day)
(Year)
4 1 HEREBY CERTI F Y , That I attended deceased from
19 , to...'.2C^.....?. 19.1^.<^...
1 last saw h./.l:35alive on ...b^..(tL.fdl....t ^.. , 1‘,(^'..9...., death is said to
have occurred on the date stated above, at
I ^ STS A A ,
DEA
(a)
\.Xii W
u
WAS CAUSED BY: IMMEDI/
Due
(b)
±\.. ..C.Q.Lki...!?....ff2D....&. .^... ..i. ^..!.2:...LL
P r—
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
'V-
Was autopsy performed? ....k?r.C. .,
(^ha), test gon^rmed diagnosis ? .L..b..Q,..Y^.Ct^....L..C../!^...rr....p..9..il!:.b..i.^^^
5 Was/diseasc
5 ^Was'dis^^e^or injury in an^ way related to occupation of deceased? tk:..
If so.
DATE OF BURIAL
^ FUNERAL DI^CTOR
ADDRESS 9.....kbf.l.«.e.a,...S.t....,^^^ .Jp.s.4o.a,.,.,Kas
Received and filed
.iftillL
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED fliarri»a
or DIVORCED
10a If married, widowed, or divorced ATlt.nnat.t.ft BaldaSSaTO
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
..Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Bartender
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
Self £ni|)loyed
018*10-4
16
BIRTHPLACE (City)
(State or country)
20
FATHER^ Marcello Catalano
18 BIRTHPLACE OF
FATHER (City) .
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
Porcari
s ^ c/ ■>? / / *ry
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Italy
Informant
(Address)
Hjitonette Catalano (wife)
^2^""SuMar""St
EREBY 0ERTIFY that a '^^tisfactory standard certificate of death
5M B^ORE theAuriaLor transit permit was issued:
(bate of Issue of Per
other)
Uu..
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
JAN 1:11950
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending phyeicianc 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 pf
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 deceas^ had retired from busine^,
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.
M R-301A
TRUCTIONS
FOR
IL CERTIFICATE
n giving
5 OF DEATH
not enter
e than one
se for each
, (b) and (c)
does not mean
7de oj dying,
heart failure,
, etc. It means
■ase, or compli-
which caused
tions, if any,
gave rise to
cause (a),
g the under-
cause last.
sditions contrib- ^
) death but not ^
to the terminal
condition given
Chapter 137,
: 1954, requires
ians to print or
the cause or
of death on
ertificates, and
r 48, Acts of
equires Physi-
o print or type
nder signature.
1-6-59-925686
st
(County)
\
(City or Town)
(HI;? dlDtnmnnuipaltl^ of MaHaartfuarttH
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
No.
2 FULL NAME
‘3
To be filed for burial permit
with Board of Health
or its Agent.
STANDARD
p CERTIFICATE OF DEATH Registered No
/ / _ c /CD y 7~ ^ death occurred in a hospital or institution,
Z.. St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
f (Was deceased a
..-iU. S. War Veteran, hlrf\
[if so specify WAR) '.T^.
(If deceasedia a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No St
(Usual place of abode)
Length of stay: In place of death years months....s3 ...days. In place of residence. years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
DEATH*^. .y/4yVMf?,y: 9. iflo
(Month) (Dav)e (Year)
(Day)>
(Year)
4 I R2BY CERTIF Y ^ That I attended deceased from
, 19.-yQ..„to V I9..6i.C^
I last saw h..v(mlive on .... JZ.ct.n-, ^ , i^.Uc. ., death is said to
have occurred on the date stated above, at // I INTERVAL
' BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) i j^ vvt. S
Due To
(b)
<?..k.aY..k.
'
Due To
(c)
OTHER
SIGNIFICA
CONDITION'
w C
vs • /
/■
Was autopsy performed? J.Zm..C. i
What test confirmed diagnosis - -
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Address) ltj..\..|4db..U v 0 pi V ate 14 9i o
, tf.. U..(?i.!9..
Place of Burial or Cremation (City or Town)
bi.f.Em..izrM. i..x^.'9..i.u.o.e.h'..{.ah^^^
Place of Burial or Cremation (City or Town)
DATE OF BURIAL . / 0
^ FUNERAL DIRECTOR
ADDRESS
./.^.^....{Q..C^^Y-..SE:i
Received and filed 19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
A.--//
10 SINGLE (write the word)
MARRIED g,
WIDOWED
or DIVORCED
10a If married, widowed- or divorced/^ - ,
HUSBAND of C^..<Z..^..U.^..ft:...
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.S?.!(?...Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
durihi
(kind of work done durihg most of working life)
14 Industry
or Business:
IS Social Security No. ... ^EJZEZ^Z^ZZZZZZoE^ZZ^..
16 BIRTHPLACE (City) yfp.,^
(State or country) » ^ S "
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
19 MAIDEN NAME
OF MOTHER
/?(- SS / yQ.
(c., e, L. ^
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
fr,icsLA^.±£l>..
(Address) '?,o /9 Uu y /'f y' 0_
I HEREBY -^CERTIFY that a satisfactory standard certificate of death
was filed wfjjll me/BEFORE thf burial (^transit permit was issued:
(Si^ture of Health or other) /
^ Z...
(Official Designation) ^Djrte of Issue of Pei^t^^ ^ ^ ^
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTJCE
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 {tersons
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.
JAN
M
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation I's 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 deceas^ had retired from busine^,
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 hoipe. 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.
LMR-301A/^‘
J.-THIS IS A
\NENT RECORD.
Jse only
E APPROVED
( ink or black
writer ribbon.
iTRUCTIONS
FOR
tL CERTIFICATE
:n giving
! OF DEATH
not enter
'e than one
se for each
I, (b) and (c)
dofj not mtan
ode of dying,
r heart failure,
, etc. It means
'are, or compli- *
uskich caused
tions, if any,
gave rise to
cause (a),
! the under-
cause last.
dilions contrib-'
s death but not
to the terminal
condition given
- Chapter 137,
' 1954, requires
ians to print or
the cause or
of death on
tertificates.
HAP. 46,9$ 9 &
HAP. 114 5545,
:HAP. 38§6.)
l-IO-SS-923886
Sarroiv , ^
(County)''^ y/fy
.Vinthrcp
2 FULL NAME-
(City or Town)
Ol0mmnmuealtl| nf IflaaHarljuafttH
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To he filed for burial permit
with Board of Health
or its Agent.
Registered No.
8
1 r'MTO A /(If death occurred in a hospital or institution,
Nn' L> . 1 1 C ' f'.i-yS?. /give its NAME instead of street and number)
.Ttiomas
(If deceased is a married, widowed or divorced woman, give also maiden name.)
St
(a) Residence. No.... 7B0..-!L....-3]iQr_e__M,».
(Usual place of abode)
Length of stay; In place of death....] years_7_ months^_y(f days. In place of residence years months
1 PHYSICIAN — IMPORTANT
' (Was deceased a
lU. S. War Veteran,
' if so specify WAR)
B.e.-se..r.e..
(If nonresident, give city or town and State)
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
1.
(Month)
(Day)
(Year)
H*: REBY CERTI
I last saw h^f^tflive on
have occurred on the date
d above, at
That I attended decease# from
- . lx ,
^
19
death is said to
Due T
(b) -
(\c \ c. i^vDgr:-AT^D in~ j 5?
Due To
(c)
OTHER
SIGNIFICANT -
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
6 -H.Ql-Y._..C.nass
Place of Burial or Cremation
DATE OF BURIAL ._
(City or Town)
ma.
19.
7 NAME OF "f "n’1
FUNERAL DIRECTOR ... L.C.S.l.lfi.._.,.i-, tT.lX.e .
ADDRESS... .3.QiO_ .3.££ich 3t Rgy ere
Received and filed.
m
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
'Vhite
10 SINGLE (write the word)
MARRIED 17 • i
WIDOWED ilQOWeCl
or DIVORCED
10a If married, widowed, or divorcei
HUSBAND of 1.8, Cy - ..4-.- - 3o,crp'-in -
(Give maiden name of wife i
(or) WIFE of
in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
t .Years Months .
ageI
KationRe_tii!e.d-ii
(Kind of worl
If under 24 hours
Hours Minutes
n^ineer
ing life)
14 Industry
or Business:
15 Social Security No..
ane-
16 BIRTHPLACE (City).
(State or country)
-3.Qmfixv-i.lJ-e-
17 NAME OF
FATHER
^^ichael ^'^au^hton
18 BIRTHPLACE OF
FATHER (City)....-
(State or country)
^cston
HF
8iSS-
19 MAIDEN NAME
OF MOTHER JuIla — ^^Tia^lfi to ^ earn
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
JJo.S-t.orL..
J'^a r i e Oue^an
ass-
Informant -
(Address) Jzaa^^ Q
here Bd ,
I HEREBY CERTIFY that a satisfactory standard certificate of death
was ^ed -with' me BEFORE th^burial or transit permit was issued:
..
(Signature of Ager»t of Board of Health ffr/other)
(Officfal Designation) , / ■ (Date of Issue of Fermit)/
U 1/ /
4
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 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.
JAKIEKSO;.'
Copii'H 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-S02 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.)
R-302
>(
^ .?..lj.ro..Q.y.'t.h.
( County )
^ (City or Town)
Qlnmmflmupaltli nf MaHaarijuHPtta
JOSEPH D. WARD BriHfTPWRtPr
Secretary of the Commonwealth ■■■.^;t^J..^Li^.c:.iw.a.uc.x....
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or Town making this return)
No.
Registered No
Wi . G - T . Rr* 1 H crp P T* St'flI’P si j (if death occurred in a hospital or institution
.■^..ir..y...r..:^..r..^:^.i...i.yg.C.W<d r.wa..':'.?;' ox Lai..,_st. | give its name instead of street and number)
9
2 FULL NAME "•.n.tf.o.n.i.Q /(Was deceased a
(If deceased is a married, widowed or divorced woman, ^ve also maiden name.) )U. S. W’ar Veteran.
^ V . . lif so specify WAR, W.O *
..9.....^?;.?!£ J.l®.- St .™-l:.D.^'.^.r.9 P > s s .
(a) Residence. No..
(Usual place of abode)
Length of stay: In place of death.. XXyeA<'s.....3.-months.i4, days. In place of residence..*. years.. .t months.... .‘.....days.
(If nonresidenL give city or town and State)
9 . ?
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
DEATH°^. .Jan.uar.y;....1.6,., I.9.6.O.
(Month) (Day) (Year)
4 I HEREBY CERTIFY. That I attended deceased from
..9/2.9. ,9...5.9.. to..../a.n.u.a.ry......l.6.., ,9..60
8 SEX
i^iale
9 COLOR
Vi/hite
10 SINGLE (write the word)
MARRIED _
WIDOWED 3i np-1 P
or DIVORCED
T..<. r...^
I last saw dJiki ive on .!J.an.uar.y....l.Q......^g.„..6.Qeath
is said to
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
have occurred on the date stated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
.?..t.a.tu.s..._^.p..i.l..ept
(a)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Psychosis with mental Ref:
years
INTERVAL
BETWEEN
ONSET AND
DEATH
(or) WIFE of..
(Husband’s name in full)
yrs
Was autopsy performed?
What test confirmed diairnosis?
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify .1)1.0.
(Signed) ..i?^..^./-.Ya.l.carc.e „. d.
( Addrei^ . R.ri.dse.wa.t.es^te.....l.Zl.9. i9....60“
!lQ..l.y.....9.r.Q.ss .f^..l..d.©.0..
Place of Burial or Cremation (City or Town) o, ii t
n.TK or J;,n,.arv IQ.. 6(11 "
(City or Town)
FUNERAL DIRECTOR ...^r.ne..§t....9..». ^a^gjano
ADDRESS ...1.4.7 ?iin..t..h.rop..
11 IF STILLBORN, enter that fact here.
12
ge4.7...
... Years.. ...44r.. Months.
...4.....
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: Mukao.vm
(Kind of work done during most of working: life)
14 Industry
or Business:
15 Social Security No.
"^difie'
16 BIRTHPLACE (City)
p ^ (State or country)
;.%.pi.e.s.
"it'aly"
17 NAME OF
FATHER
Francisco diancardi
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
italy"
19 MAIDEN NAME
OF MOTHER
^‘^arie i)imartino
20 BIRTHPLACE OF
MOTHER (City) .
(State or country)
^taly
j A TRUE COPY
! ATTEST:
Received and filed
(Registrar of City or Town where deceased resided)
,.19..
DATE
(Registrar of City or Town where death occurred)
FILEl/ .d.an, 22,, 19..6O.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
CfJ
M R-301A
TRUCTIONS
FOR
L CERTIFICATE
n giving
; OF DEATH
not enter
e than one
ie for each
, (b) and (c)
does not mean
>de oj dying,
heart failure,
, etc. It means
ase, or compli- ^
which caused
tions, if any,
gave rise to
cause (a),
j the under-
cause last.
iditions contrib-
I death but not
to the terminal
condition given
Chapter 137,
1954, requires
ans to print or
:he cause or
of death on
ertihcates, and
r 48, Acts of
equires Phyii-
0 print or type
nder signature.
N 19 1960
f-6- 59-92 5686
i
iu Wintiirop
(County)
t Stiffolk
fu (City or Town)
'tti No 4 Lorean Terrace
dnmmnmuFaltti nf MsHBarliuBPttB
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.
10
2 FULL NAME..
(If dece
give also maiden name.)
St. ...
((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, NO a
[if so specify WAR)
(a) Residence. No. 4 L.or e.an.....T..e.rrac.e
(Usual [)lace of abode) (If nonresident, give city or town and State)
Length of stay: In place of death 4.2years months. I" place of residence years.42....months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T
DEATH danuarv
16
I960
8 SEX
9 COLOR
(Month)
(Day)
(Year)
Mai p
ViThi te
19 , to rs 19.
I last saw h alive on , 19.....TTT., death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
t'ki. CrklLSt^
(a)
Due To
(b)
Due To ,
(c)
^r/er/Q ^c./er.c?ic ^
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
ks
/ah
Was autopsy performed? /TLa.
What test confirmed diagnosis? Z
5 Was disease or injury in any way related to occupation of deceased ?/?W?.
If so, specify
XI bU, bpcvliy
.ter- A.
(PRINT OR J-YPE
M. D.
6 lin.thr.o.p. G.eme.t£ry......f.iri^r.ojj., M.as
Place of Burial or Cremation fCity or 'Town) ^
DATE OF BURIAL J.^ugyry......^9-.».19.QQ.
7 NAME OF
FUNERAL DIRECTOR
ADDRESS 174 Win
o.p...S.t» Wlnthropy : flass »
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED r/aTT*'1 Pfl
WIDOWED
or DIVORCED
married, widowed,^ or Jivorced - , _ ,
.....Hel.en Claxr Johnso.n
HUSBAND of
(or) WIFE of
Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE... 75 .Years 5-months.. 21 ..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
c">iry..j3iC“S'a'l6'SiQsn-
Cind of work done during most of working life)
or Busmess: ... Wholesale glouy Sales
IS Social Security
No. 021"«05 904-
16 BIRTHPLACE (City) Philadelphia-
State or countr;
17 NAME OF
^ermasylvanla
FATHER -nanifti Pit.lft-p T)avin.
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
.Tuckerton
New Jersey
19 MAIDEN NAME
OF MOTHER Kmllle Mustin-
20 BIRTHPLACE OF .
MOTHER (City) Wii.iui.ngiJ.Qn..
(State or country)
3
Delaware
^ Informant Mts..^ Eoward...!/!.. Davis
(Addresj) — 4 Lorean TorracG.Winthrop^
^RTlf Y/ that a satisfactory sUtndard certificate of death
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 im[>or-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged lO years or over. If the occupa-
tion had been given up or changed, or if the deceas^ 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.
M R-^IA
S.;-
TRUCTIONS
FOR
L CERTIFICATE
n giving
; OF DEATH
not enter
e than one
se for each
, (b) and (c)
does not mean
>de of dying,
heart failure,
, etc. It means
ase, or compli- ^
which caused
lions, if any,
gave rise to
cause (a),
f the under-
cause last.
iditions contrib-
I death but not
to the terminal
condition given
Chapter 137,
1954. requires
ans to print or
he cause or
of death on
ertificates, and
r 48. Acts of
equires Physi-
0 print or type
nder signature.
1-6-59-925686
l< Suffolk
I® (County)
JO .
fo (City or Town)
CHlP QlDmmmmipaltlr of fJIaaBarljuapllH
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.
11
No.
..Bay... VI Home
2 FULL NAME..
Mary F. Baumelster (Gilbert)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
f(Was deceased a
^U. S. War Veteran,
[if so specify WAR)
(a) Residence. No. 1.2 ,?rQ.S.J).0C t _ AV S *
(Usual place of abode)
Length of stay: In place of death..../. years... // months .
days. In place of residence...?
St. Wlntibrop
(If nonresident, give city or town and State)
..years months days.
3 DATE OF I /'■ I'S
DEATH .>Sw.....!5^.^.....C/
MEDICAL CERTIFICATE OF DEATH
(Mont
/.z.
(Day)
llL.
(Year)
I last saw h..^fjP^ive on .. ^.Lc*,rr^...4...../t..lis. ., 19...^..^ death is said
have occurred on the date stated above, at
to
DEA-m-WAS CAUSED BY: IMMEDIATE CAUSE
(a)
[ f
CL.^d> ,c^f ^
Jl ^
Due To
(c)
3. S'
OTHER
SIGNIFICANT
olOIN li* I ^ .a
CONDITIONS A?, /f
Was autopsy performed?
What test confirmed diagnosis?
f-
INTERVAL
BETWEEN
ONSET AND
DEATH
8 SEX
9 COLOR
Female
White
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word) ’
MARRIED
WIDOWED widowpd
or DIVORCED J-U-LMIVeU
10a If married, widowed, or divorced
HUSBAND of
« (Dixe maiden name pf wife in full)
(or) WIFE of .F.ra.nk BaMe..l..8.te
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
|22_
f®-
!|se or injury in any way related to occupation of deceased
^ify
, m. d.
(P^T OR WPE ^^3^E)
(Address) Date 19..(^3.
6Mt... P.l.©a.8.ant.,. .A.rlingt.o.n I..~
12
AGE
9.3...Years....l.l.Months...3..7..
..Days
If under 24 hours
Hours Minutes
13 Usual
(Occupation :
..Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
At. home..
IS Social Security No.
16 BIRTHPLACE (City)
(State or country)
17 NA.ME OF
FATHER
Philadelphia
Pennsylvania
William F. Gilbert
18 BIRTHPLACE OF
FATHER (City)
(State or country) England
19 MAIDEN NAME
OF MOTHER
UNKNOWN
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
UNKNOWN
Place of Burial or Crem^ion
DATE OF BURIAL
^ FUNEkAL DIRECTOR Ernest P* Caggiano
ADDRESS . 14? Winthrop... St . , Wlnthrop
Received and filed
JAN19496U
(Registrar)
Mr..,.. ..Fr.ed.....A.,. .Bauia.el.,8.t.e.r,.
^ on (C>ty O'- Town) . II Informant .Oca..W4m.O A £?. u
January 29* ,qO0 I (Address) PrQSpftct Ave>. Wintbron
(Official Designation)
isfactory standard certificate of death
irial^or transit permit was issued:
RTIFY that a
BEF^E the
(SignatQte of Kgo/t^c^ Board of Health or-^th'e
7..1./.^..6:.r:^..
(Date of Issue of Permit)
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 deceas^ 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.
M R-301A
TRUCTIONS
FOR
1 CERTIFICATE
n giving
J OF DEATH
not enter
e than one
>e for each
. (b) and (c)
does not mean
yde of dying,
heart failure,
, etc. ft means
ase, or compli-
which caused
tions, if any,
gave rise to
cause (a),
g the under-
cause last.
iditions contrib-
> death but not '
to the terminal
condition given
Chapter 137,
1954. requires
ans to print or
:he cause or
of death on
ertificates, and
r 48, Acts of
equires Physi-
0 print or type
nder signature.
1-6-59-925686
cThf (Cnmmmmipaltl) nf 10aflBarl|U0ptt0
^ JOSEPH D WARD
< ^ jO,^ / A/ 1 -V i, SECRETARY OF THE COMMONWEALTH
|f division OF VITAL STATISTICS
t U/rr^^^p/l.. standard
<J (City or 1 owjn)
To be filed for burial permit
with Board of Health
or its Agent.
No.
CERTIFICATE OF DEATH
.k/z/tAJ^^r'P^
Registered No.
12
((If death occurred in a hospital or institution,
St. ) give its NAME instead of street and number)
2 FULL NAME..
/? /t^ 0 \ ^
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
f(Was deceased a y
■A U. S. War Veteran, /(/q
(if so specify WAR)
(a) Residence. No. ..
(Usual place of abode)
^/3 (^jL € S,i.
Length of stay: In place of death years..
(If nonresident, give citv nr town and State)
months .■“•rdays. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
f
(Month)
2:
(Day)
(Year)
4 1 HE R.E/B Y CERTIFY, That . I- atf^rided deceased from
I.^.L. , 19
I last saw hU^italive on 19..^.)^ death is said to
have occurred on the date stated above, at . r...Z ..m.
8 SEX
9 COLOR
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
interval
BETWEEN
ONSET AND
DEATH
Due To^^Tp /* C ^7F ^
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?^....t
If so, specify
(Signed)-...
, M. D.
(P,RINT.p!^YP^IGNATURE) /
(Address) Date......'X...(^..<^ V^.l2....
6 Af.»../y....Citr.»t..9..».
Place of^urial or Cremation
DATE OF BURIAL
(City or Town)
oft < 19 / 0
7 NAME OF .—rr
FUNERAL DIRECTOR
ADDRESS .
Ay-yi/<S<£ S77 A//s7^.
11 IF STILLBORN, enter that fact here.
12
AGE
Years Months Days
If under 24 hours
Hours Minutes
Occupation :
(Kind of work done during most of working life)
14 Industr)^
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
Ic/i// ^
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
/AAfc/
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
6- /rprtr'd
21
..^.....£^.0..x/..
Informant — >
(Address) //J 7*/ e. Sa^afiLtT ST-
Received and filed
(Registrar)
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
following rules of i>ractice:
(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 recoapiized 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.
(960 c;
Statement of Cause of [>eath. — 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 deceas^ had retired from busines,
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.
1R-301A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
lot enter
than one
for each
(b) and (c)
does not mean
e of dying,
heart failure,
etc. It means ^
se, or compli-
which caused
)ns, if any,
save rise to
cause (a),
the under-
cause last.
tions contrib-’
death but not
) the terminal
ondition given
Chapter 137,
1954, requires
ns to print or
e cause or
of death on
rtificates.
C.J.
Suffolk
(County)
Wlnthrop
(City or Town)
Ollyr QImnm0tuufalt4 nf iMaHHarljUfifttfli
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.
13
Registered No.
No.
Y/inthrop Community Hospital
2 FULL NAME-
Hugh White
|(If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
( PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. ,43Z_.Mn t hP OP_ At P 6 O t
(Usual place of abode)
' (Was deceased a
lU. S. War Veteran, rimr T
I if so specify WAR) jy.VV--. .X..
(If nonresident, give city or town and State)
Length of stay; In place of death ...years monthiL^ days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF _
DEATH
(Month)
(Day)
(\ ear)
4_^HEREBY CERTIFY, That I attended deceased from
_ .3 , \9 b to Jit M < fSC , 19. Ac)
I last saw hJv4«live on .. ’sJ...^..yY....I 19..j6—C?, death is said to
have occurred on the date stated above, at / \ J/V ^ . n
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ^hQSj 5^-.
Due To
(b)
Due To
(c) -
OTHER
SIGNIFICANT / >1 ^
HA D^Sl
CONDITIO!^ a V Obi a'
INTERVAL
BETWEEN
ONSET AND
DEyH
YJ
Was autopsy performed? /
What test confirmed diagnosis?.
5 Was disease or injury in any way related to occupation of deceased
If so, specify —
(Siaped).
(Address)yu-Vt^^^<»'
^ b<2-Y VWC
M. D,
Winthpop Cemetepy, Winthpop
Place of Burial or Cremation (City or Town)
Januapy 21st 19 6(
DATE OF BURIAL
^ FUNERAL Di RECTo^^l chard C # J Inc #
address917„ Bennington St«,E.Boston
Received and filed.
-19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED ^Widowed
or DIVORCED*
10a If married, widowed^^or decreed
HUSBAND of -M8L
^(Give maiden name of wife in full)
'n!'Wlan
(or) WIFE of
(Husband’s name in full)
II IF STILLBORN, enter that fact here.
12
AGE
?Years.
Months
19Da
If under 24 hours
....—Hours Minutes
13 Usual .Mac hi nest
Occupation : ‘
(Kind of work done during most of working life)
or ‘^Bus'iness: Bethleham -Sjt^el
15 Social Security No..01.y.»1.6»232B-^A •
16 BIRTHPLACE (City).
(State or country)
East-Boston
Mass#
17 NAME OF
FATHER
James White
18 BIRTHPLACE OF
FATHER (City)....-
(State or country)
Scotland
19 MAIDEN NAME
OF MOTHER
Jeanie Watson
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
Informant Mps • Margaret Grant-sis «
^A-idress)4^^^^^thrOP St.
/ ■»Aaauj,Axv^ V • Winthrop —
E^lriFY that a s^^factory standard certificate 01 death
BEFORE the/Durial or transit permit was issued:
of AgeiTf/^ R^ard of Health-eO^otKer)
(OfficialDesignation)
- „
(Date of Issue of PjtimitV /
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rejfistercd 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 decea^d. 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
eng.aged. insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primar>' and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any proWsion 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 l^tween 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. ^c. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a towm. 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 receiWng 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 tow'n
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 re<iuire.— Chap. 1 14. S^. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view' of the dead bodies
of pe^ns as are supposed to have died by violence, or by the action of
•chemical, thermal or electrical agents or follow'ing 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 bur>' a human body or the ashes thereof
w’hich 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
cemetei^ or burial ground in which the interment is made.
. . . Chap. 114. ^c. 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: J
( 1 ) Attending physicians will certify to such deaths only as those of persoirc^
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 know'n. 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, wxite 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 July 9,1917
DATE OF DISCHARGE July 8,1921
RANK, RATING Water tender 1/c
ORGANIZATION AND OUTFIT Beserve
SERVICE NUMBER l63.-?7-48
[ R-301A
tUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
lOt enter
than one
for each
(b) and (c)
oes not mean
e ol dying,
heart failure,
etc. It means
re, or compli-
vhich caused
ms, if any,
gave rise to
cause (a),
the under-
cause last.
itions contrib-
death but not
I the terminal
mdition given
Chapter 137,
954, requires
ns to print or
e cause or
death on
rtificates, and
48, Acts of
luires Physi-
print or type
der signature.
6-59-925686
Qlltr (CmitmmiuTfalti^ nf fHaafliarliuartta
Suffolk
(County)
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
wi<?i,throiPn)
No Win throp Comniun i ty Hospital
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
M
St.
((If death occurred in a hospital or institution,
( give its NAME instead of street and number)
2 FULL NAME..
.Jan.e....M.. Ma.cKlnn.on
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
((Was deceased a
.^U. S. War Veteran,
lif so specify WAR)
ta) Residence. No
(Usual place of abode)
55.6 Shirley
.St.
Length of stay: In place of death years months
(If nonresident, give city or town and State)
days. In place of residence... 50 years months days.
MEDICAL CERTIFICATE OF DEATH
^ DEATH*^. Janua.r^. 19.» 1.960.
(Month) ^ (f)ay) (Year)
4 1 HEREBY CE R^T -W** Y . _That I attended deceased frpm
, i9..«i^ to .L^.. w
I last saw h.Jl^.i'f^ve on , death is said to
have occurred on the date stated above, at
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .C...f^...^..<iL.k..lr.Z<i. ^..^.S:.^..ird:...Lc^....^.'..
<r
(bT ^..°..Gc...}^.\Le-<rx.../^....S^£,..J.c^...:i::^
<T / / ^ JZ — «<
'pO
Due%
(c)
t
^G^\CMiT(,^.id.ijrdt:(l.....-.L.rft../^^..\LL'?^.'^.i.
CONDITIONS .
CJ 1 .y </-
8 SEX
9 COLOR
F
White
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED oingie
or DIVORCED
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 75
AGE'
,.Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
(Occupation :
Dress D.es.lgne.r
(Kind of work done during most of working life)
or Business : .. .ClQ.thlr^...
15 Social Security No. ..
16 BIRTHPLACE (City)
(State or country DretOn. CtLYlAditr
What test confirmed diagnosis?
5 Was diseAse-qr injury in any way relaj;
If so,/Specify I
:d to occupation of deceased?
M. D.
(Signec^.-:.ynf«^,^.....^^..y. .y„.„....TT^T:....T. .ya..,.. .T. , 'W.. JU
O^TYPE ^GNAT^E) ^ /
(Address)/^?,.^<^.<^./4^..1.7^.^^ i<:lrr:.../..y.....i9^6..
6 W.ln.thr .op. C.e.m.e..t,e.r.y.
Place of Burial or Cremation
...Unthro.p.
(City or Town)
DATE OF BURIAL
7 NAME OF
January 22
..I960
FUNERAL
directorO * Ma.l ey .Bine ra 1 Home
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
J2ougal.
Cape Breton, Canada
19 MAIDEN NAME
OF MOTHEiMargaret MacEachern
21
20 BIRTHPLACE OF
MOTHER (City)
(State or country)g^^p^ Brcton, Canada
la.ab.e.lle MacKinnon
556 Shirley. St « Wlpthiro
VV.CERTIFY that^ Satisfactory standarcT cerfmcal^
ADDRESS Wl.nthrop
Received and filed J..z:.^.L....
(Registrar)
..w.La.
_ of death
FORE//he' burial or transit permit was issued:
;ent of Board ,
(Date of issue of P^mft),
^ otii«)
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 les 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 deceas^ 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.
W R-301A
rRUCTIONS
FOR
L CERTIFICATE
1 giving
OF DEATH
not enter
e than one
e for each
, (b) and (c)
ioes not mean
de o) dying,
heart failure,
etc. It means
jse, or comfit-
which
M
iW
/
ions, if any,
gave rise to
cause (a),
• the under-
cause last.
dittons contrib-
death but not
0 the terminal
tondition given
- Chapter 137,
1954, requires
>ns to print or
he cause or
of death on
irtificates, and
48. Acts of
iquires Physi-
I print or type
ider signature.
-6-59-925586
(ilnmiiimimpaltl) nf fSaflaarljUBPltfl
JOSEPH D WARD
A ttV \ SECRETARY OF THE CO
“ l f DIVISION OF VITAL
y/'K ’ W / STANDAI
COMMONWEALTH
STATISTICS
..’^anthroD
(( ity or •Ml
fown)
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
15
No.
Vinthro]^ Community
NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 PULL NAME RUSS.O..,....E.ah.V....I?.ay Il^S* Wa^Ve'teran,
/!( j j .-..j j: j .. :j._ ) | jf jf, specify \V.\R)
s.
(If nonresident, frive city or town and State)
Length of stay; In place of death years months /..days. In place of residence years months days.
(a) Residence
(Usual place of abode)
(If deceased^is a marrred, widowed or divorced woman, give also maiden name.)
,i“
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T T
DEATH J.an 1.9.
(Month) (Day)
..1.96.0..
(Year)
4 1 HEREBY CERTIFY,-. Thatnl i
6.0 to ,
)0 , yv - , 1? , '
. at4..*..Q.S A„*.M .
attended deceased
I last saw hXH^hve on .. 1-.19«60 , •'
have occurred on the date stated above
19,
4'cr
8 SEX
9 COLOR
M
V/hite
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
1) • At al e c t as is of lun gs
2. Congenital heart
Lisease.
congenital abnormal
(b) ities.
4» Club hando and feet.
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
INTERVAL
BETWEEN
ONSET AND
DEATH
PERSONAL AND STATISTICAL PARTICULARS
10 SIN(iLE (write the word)
MARRIED
WIDOWED
or DIVORCED S
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.
S Was disease or injury in any way related to occupation of deceased?
If so, specify
(Siamed)
, M. D.
biagi
A r IN • 'ff Lrr
' ‘ ITOINT 6r TY>E' SiGNAfUREJ ,
(AddressJ^.^6 Ff ifiG ©bO-Il- S t I>ate.^.~ ? P“6..Ql
6 s t on ■ Mass.'.,
place of Burial or Cremation "2 2LL 'J'^ity or Town) *
DATE OF BURIAL Vi^.
(Registrar)
12
AGE..
..Years Months Days
If under 24 hours
Hours.^...^. Minutes
13 L'sual
(Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City) ....
(State or country)
V
17 NAME OF
FATHER
Russo , — Augustine
18 BIRTHPLACE OF
FATHER (City) E.Q.S..t5..0.Il..y KQ.SS.
(State or country)
19 MAIDEN NAME
OF MOTHER O^Brjen, Caryl
20 BIRTHPLACE OF ^
MOTHER (City) S.Q.s..t..o.n., X:ia.£a..
(State or country)
21
Informant
(Address)
EBY CERTTIFY^hat a saiisfactory standard certificate of death
_ fed <?itb me BEP©RE the jterial or transit permit was issued:
, (S^atureisj^AgfBl- of Board of Health or Irtner) /
[Official Designation) / / (Date of Issue ^ Permit}
i-' k ,J
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
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.
JfAU t ■ 11960
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 bad been given up or changed, or if the deceas^ 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 i^rson 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.
« R-301A
RUCTIONS
FOR
. CERTIFICATE
1 giving
OF DEATH
not enter
: than one
e for each
(b) and (c)
{oes not mean
it o] dying,
heart failure,
etc. It means
ise, or compli-
lehich caused
ft
«
a
ions, if any,
gave rise to
cause (a),
the under-
cause last.
a
c
•P
I
&
iitions contrib-
death but not
0 the terminal ^
ondition given
■ Chapter 137,
1954, requires
ins to print or
le cause or
of death on
rtihcates. and
48, Acts of
quires Physi-
print or type
ider signature.
■6-S9-92S685
®iyr Qlmnmomuraltlj nf UlafiaarliuarttH
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.
16
\u Suffolk
)“ (County)
\o
fe CERTIFICATE OF DEATH Registered No.
, ((If death occurred in a hospital or institution,
9- No -s '"'S ' OOGdll' ViOW' ( 8>ve its NAME instead of street and number)
PHYSICIAN — IMPORTANT
'1'^ f(Was deceased a
2 FULL NAME Msi'»y ..'O.T.CO.nri^l -l U. S. War Veteran.
reasea re
(If deceasTiTre a married, widowed or divorced woman, give also maiden name.)
[if so specify WAR)
(a) Residence. No
(Usual place of abode)
.... .5 Ocean View .
.St.
(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.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
/
(Month)
.1 X ./.:^A.o
(Day) (Year)
4 I H E R EBY CERTIFY, That I attended deceased from
.'. , I9.fr.l^, to^ 19
I last saw h-<t*lalive on , ISlTI^, death is said to
have occurred on the date stated above, at m. INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Aifyayri ct ~ 5 cl c
Pb“' y
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagrnosis?
S Was disease or injury in any way relate ’ occupation of deceased?
If so, specUy ....p^.;,.
: -
(Signsdl , M. D.
^
-J^PRIN^OR TYPE SIGNATURliy / ^ ^
(Address) Date...-..f!-.™..:?...
..i9.sk.r:
Hc^....Crass Malden
e of Kurial or Cremation (City <
Januar.y....25.y
Place
DATE OF BURIAL
(City or Town)
1'60.....
7 NAME OF . ,, IT. V
FUNERAL DIRECTOR .. .Mauri.c.e. ...W. .KiT.by...
ADDRESS 2I0....tfinth.r.o.p....S.t....
Received and filed
□OTSOgsii
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Femalft
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED Widoved
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of David. O.’.Connell
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.
..ao...
Years Months..
..Days
If under 24 hours
Hours Minutes
13 Usual
(Occupation:
..H.o.us.e.wife
(Kind of work done during most of working life)
14 Industry
or Business :
.AI....Home..
15 Social Security No.
..None.
16 BIRTHPLACE (City) .. ...S.t.* J..Qhn.
(State or country) N . F .
17 NAME OF
FATHER
Richard Hiirrell
18 BIRTHPLACE OF
FATHER (City)
(State or country)
St- John
19 MAIDEN NAME
OF MOTHER
Unknovn-
20 BIRTHPLACE OF
MOTHER (City) .S.t..« ... J.OhU
(State or country) ^ ^ p ^
I "
Informant
(Address)
— ' ~ ~y / -
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed me BEFORE ^e buri^: or transit, permit was issued:
•'
^ ^ ' (Signatjl^^f Agent of Board of Health or other)
■4''
(Official Designatioqy/' ^ate of Issue of Pj/mit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
\'b%
JAN 251980 A/'
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending phyiicians 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 physician* 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 deceas^ 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.
/\
I R-301A
It-H
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
$
ft
lot enter
than one
; for each
(b) and (c)
f
oes not mean
le of dying,
heart failure, ^5
etc. It means
se, or compli-
which caused _ ,
%
X
ons, i) any.
) V
gave rise to
(.
cause (a).
the under-
cause last.
)
Htions contrib- JC
death but not
? the terminal ^
ondition given
%
Chapter 137.
1954, requires
ins to print or
le cause or
of death on
rtihcates, and
48, Acts of
quires Physi-
print or type
der signature.
6-59-925686
\u S.uf.falk
1® (County)
(u.
ju Winthrap
fU (City or Town)
<
's! No 4..7... Douglas,^
QInmmnnuifaltlj nf HaHBarljuHfttB
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.
I'Z,
f(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME..
Dorothy... A... Oes.terle
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
f(Was deceased a
..■iU. S. War Veteran,
(if so specify WAR)
.47 Douglas^
,.St.
(a) Residence. No
(Usual place of abode) ^ nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January . .22* 1960 .
(Month) (Day) (Year)
4 1 HiEREBY CERTIFY, That I attended deceased from
.//...C 19..^:?.., to lIi±. 19^..?....
I last saw h. fe?alive on , 19..S?..9., death is said to
&...../$. m.
on
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .../^..ftr..‘'...I:...e
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? .A/.a
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ^
Y)
M. D.
(Signed) ...
ij A/-
(M'i'NTOR’WpO / ,
(Address) Date. 19.*^
■iXr-Tfv
..Old Calvary
ce of Burial or Crematio
Place of Burial or Cremation
DATE OF BURIAL
Boston
(City or Town)
..J.aauary.....2S...... 19..6.Q.
7 NAME OF . . . , , c- • 1-
FUNERAL DIRECTOR Maiiri CP V Kirny
ADDRESS ....2lO....WinthrojpL...St.«...................
Received and filed ..J./liDi...li.i)....iyfeiU.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVOR(:EIM^|»|<-i e^(\
10a If married, widowed, or divorced
HUSBAND of :
(Give maiden name of wife in full)
.Th.Qiuas...A....O.e.ste.rle.
(Husband’s name in full)
(or) WIFE of
11 IF STILLBORN, enter that fact here.
12
AGE. 61 ..Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Hair.dr.e.s.s.er.
(Kind of work done during most of working life)
14 Industry
or Business:
-Self
15 Social Security No.
012-18-4l9a
16 BIRTHPLACE (City)
(State or country)
Boston.
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) .
(State or country)
James J Danahy-
Boston.
19 MAIDEN NAME
OF MOTHER Mary A Sweeney
20 BIRTHPLACE OF
MOTHER (City) BOStOU..
(State or country)
Informant ...ThQmas....A....OAterle.
(Address) ■*" ^ ■*- —
47 Douglass St.
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed witlTTme BEFORE the bupal ot trarisit permit was issued:
Health or other)
(Sign^tOre of Agent of Board of I
(bfficiai Designi^QA) (D£te of Issue of Pe/mit)
|0
V. h ^
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
\
RULES OF PRACTICE
VO •'
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 ol
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.
JAN 2 5 1960 fS
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 deceas^ had retired from busine^,
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.
■ \
Copies of returns of deaths which occurred in your city or town in cast the deceased resided in another city or town
at the time 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, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, C. I,.)
R-302
Essex
(County)
Lynn
(City or Town)
Lynnvlew Hosp.
Qlximmonuipaltlj of
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Lynn
(City or Town making this return)
Registered No.
18.
V xa.jkv — — — — death occurred in a hospital or institution.
No - St. ( give its NAME instead of street and number)
2 FULL NAME D..a.Y..i.d......BP.et
(If deceased is a married, widowed or divorced woman, give also maiden name.)
30 Highland Ave,
(a) Residence. No
(Usual place of alrade)
St._
i(Was dei
U. S. W
;n«®
deceased a
ar Veteran,
■■ WAR)..
(If nonresident, give city or town and State)
Length of stay: In place of death years months...l^days. In place of residence ...years months days.
MEDICAL CERTIFICATE OF DEATH
DATE^or Jan, dk, I960
(Month)
(Day)
(Year)
I last sa\djWl alive on
, at s5Ka
tended deceased froiff ^
, 19
19 death is said to
have occurred on the date stated above
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cerebral thrombosis
(a)
1 dy
D’^^er al 1 z t eM i|b
Due To
(e)
siGmFiCA:I^7.P.C„ar
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF
STILLBORN, enter that fact here.
12
If under
24 hours
aAQ
Ye^s Mon<^ - Days
Hours
Minutes
Was autopsy performed?
What test confirmed diagnosis?
no
clinical
5 Was disease or injury in any way related to occupation of deceased HO-
If so, specify
(Signe<C.la..r.3.n..c.Q London
(AddreIfl?miYl.Qli....HO,;^.# Dat,
Opk Hill
M. D,
1/24/60.19
Peabo^ ZI
'i/2.^/60 Town)
Place of Burial or Cremaf^n
DATE OF BURIAL 19...
7 NAME OF Arnold Golov
FUNERAI^Ig^^-T^^.^^^ Sf.BrOOklto-
ADDRESS -
Received and filed p 1 Q ^9^0 - 19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
lfl_
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
or DivQgggyiad
10a If married, widowed, or divorced
HUSBAND of..
Ruth((iEl,ilind^^
,e of wife in full)
(or) WIFE of..
(Husband's name in full)
13 Usual
Occupation :
(Ki
ing most of working life)
14 industry
or Busin
Sterling
15 Social Security No
JEUL
16 BIRTHPLACE (CitVj^^.
(State or country) nUfllfll,
17 NAME OF
FAT
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTH^ather
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Baranbarg
RwiBHle
21
Inform;
(Addle;
A TRUE CQ,
.ATTEST,
DATE FILED
^Towh' wheye. dedfli occurred )
2/V60
tc T'iSirartTirivmi!) «i
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FEB 101960 »«: -
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831- 5-^
(bsWv ; «t»*»T *» -.TtEnEr
VI R-301A
RUCTIONS
FOR
. CERTIFICATE
. giving
OF DEATH
not enter
than one
i for each
(b) and (c)
dofs not mfan
It of dying,
ktart faxlurt,
etc. it means ^
St. or tompli- *
which caused
ons. if any,
gave rise to
cause (a),
the under-
cause last.
Itions contrib- ■
death but not
0 the terminal
ondition given
Chapter 137,
1954, requires
ins to print or
le cause or
of death on
srtificates.
3 DATE OF 7 A i, 2. 4
DFATH ^ 7
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
(Month) (Day)
■^(Year)
4 I HEREBY CERTIFY. That
I attended deceased from
Ig (County^
Qlntiittuimufaltli nf fHaafiarljufirltfl
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. ,
FULL NAME- '' A/f ////4'^'J )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. s., .
(Usual place of abode)
Length of stay: In place of death years months days. In place of residenc
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)-
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
I last saw j
have occurred on the date stated above, at
fa/L<xali
M..
> 19^-j^ , death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
iei.e/f’C'Sf.K
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
UM.
m.
Was autopsy performed?-
What test confirmed diagnosis?_C/./J!^L/^./^y4j^Li^
5 Was disease or injury in any way related to occupation of deceased
If so, specify-
(Signed)
(Address
M. D
Date/^^i^ . - 19(^0
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
/i
(Kind of work done during most of working life)
14 Industry
or Business:.
15 Social Security No
16 BIRTHPLACE
(State or country)
''rATHEg'' //
18 BIRTHPLACE OF
FATHER (City)-.
(State or country)
19 MAIDEN NAME iV.'X*-
OF MOTHER 7^^/fyiJ ^ /f
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
that a satisfa«ory standard certificate of death
iEFQf^ the bun^ or transit permit was issued:
gent^finard of Health or
.
(Date of Issue of Pewhit)'
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or reipstered 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 retjistration 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
eng.aged. 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, qr 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. 1 14. Sw. 4.S.
G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of pei^ns 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 194.S.
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
M 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
cemeteiT 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 rettrdd. . 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....... |;r^.
SERVICE NUMBER
[ R-301A
■THIS IS A
ENT RECORD.
B only
APPROVED
nk or black
iter ribbon.
UCTIONS
FOR
CERTIFICATE
giving
3F DEATH
Dt enter
than one
for each
b) and (c)
oes not mtan
of dying,
hfart failure,
tc. It means ^
f. or compli-
yhich caused
ts, if any,
ive rise to
cause (a),
the under-
ause last.
\ons contrib’^^
leatk but not
the terminal
ndition given
Chapter 137,
requires
8 to print or
cause or
f death on
tificates. ' — ’
kP. 46,H 9
P. 114 5545,^
AP. 38S6.) ^
v;-.
fe
3>5e-923ea6
(County)
Ol0tnmnttuiealt4 nf i®aHjaarl|UBrtta
(City or To*
f - l r £
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.
20
Registered No.
2 FULL NAME
(If
deceased is a married, widowed or diw)rc
f(If death occurred in a hospital or institution,
-St. (give its NAME instead of street and number)
(a) Residence. No.
(Usual place of abode)
lTw)rced woman, give also maiden name.)
I PHYSICIAN — IMPORTANT
' (Was deceased a
1 U. S. War Veteran,
' if so specify WAR)
St.
Length of stay; In place of deat
(If nonresident, give city or town and State)
years— months days. In place of residence^^l^'y^rs months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH -.
(Month) (Day) (Year)
4 H E REBY CERTIF Y , That I attended deceased from
_ G ysj , 19.^1^, \o !2-..y ., 0
I last saw h ^J^yalive on , 19- ko, death is said to
have occurred on the date stated above, at
DEAT^WAS CAUSED BY: IIUUDIATE CAUSE
(a)
- SoiD ei
Due To
(b)
Due To
(c) - ...
OTHER
SIGNIFICANT
CONDITIONS
Wa^ autopsy performed?
What test confirmed diagnosis
INTERVAL
BETWEEN
ONSET AND
EATH
5 Was disease or injury in any w/y related to occupation of deceased 7?q
If so, spec.eHAFH.R.q 4TTRRB ^
(Signed)
(Address)i
M. D
Place of Burial oyCremation
Date
/
emation (City or Town)
DATE OF BURIAL 19^^
NAME OF n ^ . j. /I ' /
FUNERAL DIRECTOR ^ r> /a
Co sin g/zcpkD>£'
ADDRESS
Received and filed
f-E3-T-19S0
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
r
9 COLOR
lU
10 SINGLE (write the wond)
MARRIED iflJ
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
, /(Give maiden name of wife in full)
J^J2.lJkMUz. 4jajluJ
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
ears Months Days
Or^“fpatinnr fy^ A ^ Uj !
If under 24 hours
Hours Minutes
(Kind of work done during most of working life)
14 Industry
or Business
15 Social Security No...
16 BIRTHPLACE (City)....
(State or country)
17 NAME OF
FATHER
M
u
€U/ ^
18 BIRTHPLACE OF
FATHER (City)..
(State or country) TtosSrd
19 MAIDEN NAME
OF MOTHER
/4a/ LU LL
20 BIRTHPLACE OF
MOTHER (City)
(State or country) C / ^
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK. RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
F
c n
1. U
ir.3
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 dunng 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.
R-301A
UCTIONS
FOR
CERTIFICATE
eivlng
3F DEATH
>t enter
than one
for each
b) and (c)
oef not mean
of dying,
heart failure,
tc. It means ^
\ or compli- ^
>hich caused
is, 1/ any,
ive rise to
ause (a),
the under-
last.
ause
ons contrib-’
■eatk but not
the terminal
ndition given
Chapter 137,
95A, requires
s to print or
cause or
r death on
klficates.
\<
Ih
1 Ju>
So
Ju
fu
■<
!•->
\o.
<r (T
fu A k
I /ii~hr
(Cit;^ or Town)
(Hljr Olommnnuipaltli of
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Beard of Health
or Its Agent.
21
Registered No.
No.-
f(If death occurred in a hospital or institution,
t.lgi^
2 FULL NAME
\y
7p)rocjK y
(If deceased is a married, t/idowed or divorced womatu give also maiden name.)
A.
-St. (give its NAME instead of street and number)
( PHYSICIAN — IMPORTANT
(a) Residence. No
(Usual place of abode)
St..
* (Was deceased a
jU. S. War Veteran,
[ if so specify WAR)-
Length of stay: In place of death years..
months
/ (If nonresident, give city or town and State)
days. In place of residence. t.7x - years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
4 I H E R
tMonth)
y)
■(^ar)
BY CERTIFY, That I attended deceased from
19-..'^^ to.
I last saw h^fTalive on '
have occurred on the date^^ated above, at m.
19
leath is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?-
What test confirmed diagnosis?-.4rSt^r
INTERVAL
BETWEEN
ONSET AND
DEATH
13 Usual A i 1 ^
Occupation: I. ..4.t..iO_l2)
(Kind of work done during most of working life)
5 Was disease or injury in any way related to occupation of deceased?
If so, specifyARTHUR Ha VILKER .
(Signei
(Address)./'-._£
Place of Bunal or Crematic
Date
M. D,
DATE OF BURIAL
(City or Town)
1^-D
ADDRESS
7 NAME OF
FUNERAL DIRECTOR-..!
Received and filed
ft&T-^960-
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
Uy'UifTS-
10 SINGLE (write the word)
MARRIED
WIDOWED i li .{ ... ^ I
or DIVORCED^ lUO^dl
\10a If married, widowed, or divorced
HUSBAND of
(Give mai
iden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
Years Months — Days
If under 24 hours
Hours Minutes
14 Industry ^ i , ,
or Business: Cy
15 Social Security No..
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
e iL
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
/4^bfy/OL
Informant — A.Qy.L^
(Address) 7 a C I Si'
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed BEFORE the hMT^al orr;trahsit perpiit was issued:
ignature^ Agent of Board of \
Health or o^^r)
(Official Designation)
(Dat^^f Issue of^ermit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rejfistercd hospital medical officer shall forthwith, after the
death of a pcrsfm 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 f^>r 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
eng.Tged. 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 neglt^t 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 forW-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 he obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14. Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of pe^ns as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or follovving 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 ^erk of the town where the body is to be buried
or the funeral is to be held, or from a person appqinted 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 form of
injury, have died without recent medical attendance or whose physicifn^is^bsent
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 dunng 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
\:
^uiXolk...
(County)
®I|e Commonfnealtli nf (Ma9aacl|UBetts
JOSEPH D. WARD
secretary of the commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
(City return)
22
[o Ct^fii^Pfbwn)
■eil'- i'O-tX-fce to Gtlf isea.- iienTOria-1 Hoafi-i name instead of street and number)
Registered No
(If death occurred in a hospital or institution,
2 FULL NAME..
(if deceasft*is*3nai€l^,^^5(S?Hed or divorced woman, give also maiden name.)
f(Was deceased a
.(U. S. War Veteran,
(if so specify WAR)
(a) Residence. No ... .TaQ e •
(Usual place of aboae)
• ^
* (If honresident, 'give city or town
and State)
Length of stay ; In place of death years months days. In place of residence.. .^«>...years months
21
..days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(M
d3ai>n ,
(Year)
4l 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.)
Acute myoeer dial infarction
S Accident, suicide, or homicide (specify)
Date and hour of injury 19...
If accidental, was injury causally related to the death?
13
If under 24 hours
AG^^. Years
Days
Hours Minutes
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 ?
Manner of
(How did injury occur?)
(Specify type of place)
Injury
Nature of
Injury
While at work? Was autopsy performed?
■faSr
6 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) A M. D.
"Ml'Ciia"Ol--'A
(Address) Date-
"Bdstbn
Piac^Q'tfeaiJP?S«fen.#^^
DATE OF burial ,
19..
8 NAME OF
FUNERAL DIRECTOR
A-m'old
Received and filed 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
ll^^S^i^Ted, widowed,
HUSBAND of
10 COLOR
11 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
rxn^le
d
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 IF STILLBORN, enter that fact here.
14 Usual
(Dccupation :
wiSgrMbnfeAijiftE^Bt of working iifej
IS Industry
or Business:
IS Social Security No.
Sfciftn day Supply
17 BIRTHPLACE (City)
(State or country)
18 NAME OF
FATHER
Fh£-^ — fij; ton « ’.lass
19 BIRTHPLACE OF
FATHER (City) .
(State or country)
20 MAIDEN NAME
OF MOTHER
21 BIRTHPLACE <3.
MOTHER (City)
(State or country)
Russia
^|ther Lebowitz"
22
Informant
(Address)
_ _da'""''7o'oi3e^
TRUE COp5*.^^ 1x1 tilT'Op^
rredj
A
ATTEST:
Jan,2,19(
DATE FILED - 19..
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE fO.l.filMO.M
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-302
c-o
2 '
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18 196^1
Suffolk
(County)
Revere
(City or Town)
jjo Grover Manor Hospital
(Hi|p Olxmtmomupaltti of iEaBoarliuoptto
EDWARD j. CRONIN Reyere....
Secretary of the Commonwealth (City or Town making this return)
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Registered No -
23
St.
((If death occurred in a hospital or institution.
I give its NAME instead of street and number)
2 FULL NAM .3 i. sbc 6 ,( F.or^
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No
(Usual place of al>ode)
Length of stay: In place of death years....3....months ?..days. In place of residence ^..years months days
(Was deceased a
U. S. War Veteran,
if so specify WAR)..
X W4n t hr qpi,
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
^ DEATH^^ ,..4.8nu.arj .11,
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
Oc t 9,9 5.9 to .4.4..„ io60
I fast saw h. .Q.Clive on Jan.,......!!. l^.Q., death is said to
have occurred on the date stated above, at .....P .*..3Q.A--#....m.
8 SEX
9 COLOR
Female
White
DEATH WAS CAUSED BY:
Uremia
IMMEDIATE CAUSE
(a)
Due ToCerebral vascular
(b)
accldant
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
OEATN
2i4.hr S ,
9mos
... ~ . no
Was autopsy performed?..—
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?.... W3i.
I f so, specify
(si„,«)..5a;5e| ,?'i, Burns „ „
537 3roa<Jway t /in cn
( Address). Date.._.JLy_H 19.U.U.
Woodlawn
Place of Burial or Cremati
DATE OF BURIAL
tfanuary
liverett
i^it^ or Town)
.60
.19.
7 NAME OF Blsbee ^ Son
FUNERAL ^^^CTg^.j^.^..Q.^^..._^.^g..... ...g.g.^ ^
ADDRESS Z - ^
Received and filed f£ B l g 19_
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED, ... ,
wiDowEDvi/ i dowe d
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of..Erne.st E._ Blsbee
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
a^7. ...Y ear^. Months. jr..7..Days
If under 24 hours
Hours Minutes
1.1 Usual Housewife
Occupation :
(Kind of work done during most of working life)
or"B;;^s^ess:....9.W3 hpme.
15 Social Security No.. none
16 BIRTHPLACE (City). S..t.*
(State or country) fj R ^
FATHkR^'<iward Farren
18 BIRTHPLACE OF „ . _ ,
FATHER (City)
(State or country) N. B.
19 MAIDEN NA
OF MOTHER
Kellawaey
20 BIRTHPLACE OF
MOTHER (City).......
(State or country)
St* John
rr-r’S-
21
Informal
(Addresi
A TRUE COPY
ATTEST:
DATE FILED
(Registrar of City or Town where death occurred)
; January _ 13 „ ,9 60
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22 a!
to W
..M.lddl.3.s.e.x..
(County)
..W.al.t..ham
(City or Town)
(EmnmatiuiFaltii of fEaHoort^uortto
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Walbham
(City or Town making this return)
38 *
24
Registered No.
No..
,..W.a.X.t.e.r.....E.*....F.e.rna.l.d StaM....S.chool.
..St.
I (If death occurred in a hospital or institution,
! give its NAME instead of street and number)
2 FULL NAME C.Mr.l.0a....K.ftp..l.P.Yi..tz
(If deceased is a married, widowed or divorced woman, grive also maiden name.)
deceased a >
War Veteran,
specify WAR,
(a) Residence. No.... 2.0.Q...Sthlrlay st .Vi.n.tlngppp, Mas.?..*
(Usual place of abode) (If nonresident, give city or town and State)
,.j(Was .
lU. S. ’
\if so
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
S||
c ^
■cj:
c -.i
» 2-5
s.Bi'S
■ti c
u c o
c o«^
— o
PS-I*®
^2 s
ago
•C ^ .
JZ s <u
rt Jc:2
w-Sa
o se
0l tf}
W CC
3 0 0
•i:
3 DATE OF
DEATH ...
..January. 1..6.»..
(Month) (Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
...Jan* 1 19.5.9 •••. to J.an* 16 196Q..
I last saw h.i.lHive on ...JaXl.* — 1.5 l6.0.., death_is_said_to
have occurred on the date stated above, at 7.:3QfluiL m.
8 SEX
male
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED single
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
( a ) .C.or .o.nary.,...t.hr .Qmb.D.aia
Due T
(b)
tlongenli;al...cePahpal....s.pa£i.t
Infantile paralyses
Due To
(c)
siGNfFicANTMe.n.t..al....d.Qfl.c.i.Qnc.y..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
(or) WIFE of..
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
3hrs
-6 - .. 28
AG
..Year^. Months Days
If under 24 hours
Hours Minutes
Ic
life-
13 Usual
Occupation; .N.Q.n,e.
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
life
16 BIRTHPLACE (City)
(State or country)
¥lnttoop
Was autopsy performed? ....
What test confirmed diagnosis ? C.Hni.C.al..
5 Was disease or injury in any way related to occupation of deceased ? .UQ...
If so. specify
(Signed) .b..» M. Di,
Waltham, Mass* ^ 1-18 6C
(Address) .' Date 19
6 Ada.t.h....3.e.,s.hurun, W....Joxbury..
Place of Burial or Cremation (City or Town)
Ma.s s ,
17 NAME OF
FATHER
Berne t Kaplovitz
18 BIRTHPLACE OF
FATHER (City)
(State or country) RUS S i a
19 MAIDEN NA
OF MOTHER
,’l^ebecca Cohen
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
■Russia"
DATE OF BURIAL
Jft.nu.ary....l7. 19..6O
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
..TQrf.....F.un.e.ral... Service
..C.hQ.la.e.a.»....Mas.s..*
21 , , WEP School
(Address) Wav83:*leVf Mas^
A TRUE COPY
ATTEST:
V
Received and filed
FffAR' 10 1963-
..19..
(Registrar of City or Town where death occurred)
DATE FILED 19....6.Q
(Registrar of City or Town where deceased resided)
X
HARiGiC
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
OV
1 R-302
. J
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y ■*- ^
I 0-5
v«3r «r
‘•b"
c rt
U^Z
■|B 18 196i:
Suffolk
(County)
Revere
(City or Town)
Grover Manor
No..
Oil;? (HommomuFaltli of MaBoadyuorttH
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Revere
(City or Town making this return)
COPY OF
CERTIFICATE OF DEATH
Registered No
..2.5
.St.
I (If death occurred in a hospital or institution,
t give its NAME instead of street and number)
2 FULL NAME ...Enanc_e.,s.„„Mag.e.fi....,..tS..ainp.s..on^^^ - / (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) fj. S. War Veteran,
L if so specify WAR)
(a) Residence. N0....6....C .pllTt ... ROad MnthrC^
(Usual place of aliode)
Length of stay: In place of death years..l months.... IQlays. In place of residence
(If nonresident, give city or town and State)
-..years months days.
MEDICAL CERTIFICATE OF DEATH
' DEATH®^ ..January 2k.
(Month) (Day)
.1960.
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
P..e.c emb.e.r. 5 19...S.9, to.J<i^yya.O: .2it.*-..., i«^0
I last saw h0.I^live on «T RTl ^ 21l~-, 19.. 60 death is said to
11 • lOP
have occurred on the date stated above, at ....r:..-..?...«'.>:..i...*.m.
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
5'emale
White
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Uremia
(a)
INTERVAL
BETWEEN
ONSET AND
DEATN
l8hrs .
Due ToC arc inoraa of stomach
(b)
Due To
(c)
OTHER
SIGNIFICANT _...
CONDITIONS
-tto-
6inos .
Was autopsy performed?...- _«..'S..x_.A._._.a —
What test confirmed diagnosis?
S Was disease or injury in any way related to occupation of deceased ?...^.9...
If so, specify-
(Signed)..
James P, Burns
"Broadw^
( Address ) £i V.fir.&.t!u
Winthrop ^
Place of Burial or Cremation
M. D
..Date..
1/26 M
Wlnthro"^
(City oSjTown)
DATE OF BURIAL .-..rr..:..-
i_ (Lity osj 1 own) .
Janua^ __2o
Maurice W, Kirby
•wimhi‘“crcr"
ADDRESS f ' fi..-
7 NAME OF
FUNERA
Received and filed..
•p£g l§ i960
„19_
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .J.sm.e.s.....E,*,...,Magee
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGli3..... .Y ears Months -Days
If under 24 hours
Hours Minutes
13 Usual Housewife
Occupation
(Kind of work done during most of working life)
14 Industry
Kiess: At .home......
IS Social Security No.-
none
16 BIRTHPLACE (City)-..
( State or country)
■W, ST"
FATHER^ Joseph Sampson
18 BIRTHPLACE OF
FATHER (City)
(State or country)
W. S-V
19 MAIDEN NA:
OF MOTHER
?mria (Cannot be learned)!
20 BIRTHPLACE OF
MOTHER (City) —
(State or country)
H". S-;
21
Informant
(Addressjfe G durt R d , . J¥iri tViynn
A TRUE COPY
ATTEST: '
/
DATE FILED
(Registrar of City or Town where death occurred)
January g8, j, 60
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^ R-301A
I -THIS IS A
^NENT RECORD,
se only
APPROVED
c ink or black
n’riter ribbon.
liRUCTIONS
FOR
|. CERTIFICATE
: giving
J| OF DEATH
loot enter
§ than one
Lt: for each
■ (h) and (c)
not mean
mie of dying,
heart failure,
U etc. It means ^
ii le, or compli- *
^ ...l: ■
r which caused
di’ns, if any,
^ave rise to
V cause (a),
;a the under-
acause last.
'» tons contrih- ■
tsdeath but not
fthe terminal
ndition given
1
Ml Chapter 137,
fl|954, requires
Id It to print or
I; cause or
t f death on
c tlfieates.
C\P. 46, 9§ 9 &
CKP. 114 §§45,
(lAP. 38§6.)
IM D-56-9238S6
Town
No.
QImnmottmealt4 of iHaHaarijuarttfi
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.
26
Registered No. . —
2 FULL NAME
(If deceased is a
/(If death occurred in a hospital or institution,
-St. (give its NAME instead of street and number)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death
ar^ij^d’ widowed orVivor^yd woman, give also maiden name.)
St..
PHYSICIAN — IMPORTANT
(Was deceased a — y
U. S. War Veteran, Q
specify WAR)
years months, days. In place of residence years
(If nonresident, give city or town and State)
/o
years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
Febniaiy
(Month)
lx
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
_March JL, i9 J*8 , to Feb» , i960
I last saw hijQa live on JflTl — 3X^ , 19. 60 , death is said to
have occurred on the date stated above, at _ 7ao,a fm
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic heart disease
(a)^
fb)®J° Generalized arteriosclerosis
BtaQwtgsxjfeattHS
OTHER
SIGNIFICANT
CONDITIONS B
INTERVAL
BETWEEN
ONSET AND
DEATH
6 yrs.
10 yrs
ttiguoi
12 yrs
Was autopsy performed? HO
What test confirmed diagnosis ’OlXIliCal &,_.liabOra.tOTy..
5 Was disease or injury in any way related to occupation of deceased?..?!©
If so, specify^... .Tr.a^-ns.t.ein t Jr ,
(Signed)_l!'JZ3L..f
(Address)
m. d
We Feb«. 1^1960
Place of ^pial or Crematio:
DATE OF BURIAL
(City or Town)
^.f.
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
TBOI
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SE.X
9 COLOR
10a If married, widowed
HUSBAND of
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED'
ilvorced '
jive maiden name of wife in full)
ivrite tne wora;
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here. ~
AGE^/^W
Years..
13 Usual
Occupation:
If under 24 hours
..Hours Minutes
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social
ial Security No.
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
’^citerOA.ef. dy.
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
'(St
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
ory standard certificate of death
1 or transit permit was issued:
ent/<7f "Btoard of Health (Mother),
(Official Designation)
- -“V-.4
U (Date of Issue of Permit) /
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 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.
FEB I960 f.'l
R-301A
Iructions
liFOR
|| CERTIFICATE
] giving
5l|OF DEATH
iot enter
I than one
j for each
1(b) and (c)
n pes not mean
oj dying,
mlheart failure,
Mefc. It means
■ e, or compli-
mvhich caused
ns, if any,
ave rise to
ause (a),
the under-
ause last.
(iOBj contrib-
ofeath but not
the terminal
idition given
{Chapter 137,
i 154, requires
f s to print or
t cause or
E death on
ihcates, and
>8, Acts of
ridires Physi-
tclrint or type
lipr signature.
Suffolk
(County)
Winthrop
(City or Town)
Winthrop Commi
No.
(fummonuipaltij nf f®aflHarl)UBPltH
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
j DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
ty Hospital
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
St.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
f (Was deceased a
2 FULL NAME .‘'VH (U. S. War Veteran, JJq
Burton Barnes
(If deceased is a married, widowed or divorced w’oman, <?ive also maiden name.)
[if so specify WAR)
(a) Residence. No. 150 Highland AV6., WlnthTOp, MaSS, St.
(Usual place of abode) 2
Length of stay: In place of death years months days. In place nf^esidence years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Februaiy 2,1960
(Month) (Day)
(Year)
B Y C
I
im
I last saw h alive on
aOKT I F Y , . Th^ 1
W Feb. 2,
I attended deceased frj
19.
„60
6Q
8 SEX
9 COLOR
'ale
Tiiite
have occurred on the date stated above, at
1,09:
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Coronary Etebolus
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Fracture Left Feraur
INTERVAL
BETWEEN
ONSET AND
13 Dag^
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED . ,
or DIVORCElj.:^ C 'I O ^
10a If married, widowed, or. divorced t-, i s
HUSBAND of ...ire.n!],:..3...Q..;.b..:...4....P... .C..Q.f.f.l.lI.,
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
II IF STILLBORN, enter that fact here.
AGE...5..X.. Years .1. Months....J,..Z..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: :...R.«..t.i.r..a....
(Kind of work done during most of working life)
14 Industry ,
or Business : .i>;i,A.f.i«a,.g.0..p — I-OS-ii--
15 Social Security No S?.5....i~.l..'..i..T:..L.....!..^..
•G-o-
16 BIRTHPLACE (City)
(State or country)
Was autopsy performed? No
What test confirmed diagnosis? . X*Ray
S Was disease or injury in any way related to occupation of deceased
If so, specify^ ..^....
(Signed)
(Address)
aSwre')"
Reverew Maas* ? / ?/
M. D.
6 2.ur.i..t.an L.3<:En.....r:...e..o.i........ .P..e.a.b..Qdy.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL Fe.bx.uar.y 5.., 19 ..6.G.
7 NAME OF 1 , T-, , ^ .
FUNERAL DIRECTOR Q..r..c..e.i.i.a Euaex.al S e r V 1
ADDR ESS 9..1.Q. iLi.at hr.Q. J .\.Y..e...... R.e.Y..e.r e
Received and filed
(Registrar)
17 N.AME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
19 MAIDEN NAME
OF MOTHER
hf esS
L- a.>i ,?
20 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
^je,i>7oy
21
Informant
(Address)
ja.ri£.X....
■d£uL
0 e
,t(sftctory standard certificate of death
r tr^sit permit was issued:
(Official Designation)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING ’
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulhllment 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 deceas^ 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.
I R-301A
l;UCTIONS
fOR
RICERTIFICATE
Driving
HOF DEATH
I )t enter
•than one
til for each
)^'b) and (c)
not mean
i«l oj dying,
:» tearl failure,
iLlfc. ft means
r||l, or compli- ^
Mch caused
'U\is, if any,
• pe rije to
q ause (a),
he under-
; last.
'ons contrib-
•ath but not '
ifhe terminal
dition given
:-|hapter 137,
ffjS4, requires
ia to print or
th cause or
■ death on
eificates, and
r 8, Acts of
etirei Physi-
• [int or type
PI' signature.
19-925686
ffinmmnnuifaltli of ilaafiartiuofttB
lu Suffolk:
1“ (County)
te Winthrop 1
lU (City or Town)
\<
Q» No. ... kayf lower Nursing Home
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.
m
St
((If death occurred in a hospital or institution,
. I give its NAME instead of street and number)
2 FULL NAME.... Henrie.tt.a....Elizabeth....Ed.war.ds
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
f(Was deceased a
..(U. S. War Veteran, ■.t.-.
[if so specify WAR) N0»
(a) Residence. No. 54 Beal Street.
(Usual place of abode)
,.St.
(If nonresident, give city or town and State)
Length of stay: In place of death years 5.-months days. In place of residence IQears months days.
MEDICAL CERTIFICATE OF DEATH
^ Seat H*f. E.e..l5ruLary. 3...
(Month)
(Day)
..196.Q
(Year)
41 HEREBY CERTIFY
19...^....^ to....^....
I last saw h..(?Jalive on
That I attended deceased from
, 19..^^:?
death is said to
have occurred on the date stated above, at m. INTERVAL
' BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMII^DI/^TE CAUSE
(a)
^ ^ V /—
Due To '
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
v/
12
If under 24 hours
AGe84 Years
..7..Months..l.9 -blsys
Was autopsy performed? N.a
What test confirmed diagpiosis?
5 Was disease.or injury in any way related to occupation of deceased? (let..
If so, specify^.
(Signed^
, M. D.
.y -./....L^..<^../Ly.J<7.
/ / (HRJNT OR TYRE SIGNATURE) .
(Ltif^) 19.4^
...Winthron C.eme.t.ery.,.Wiiitlir.Qp.p Mas
Place of Burial or Cremation (City or Town)
DATE OF BURIAL 19.
7 NAME OF
FUNERAL DIRECTOR
ADDRESS .i.74......wint-hj^op- -Stp Wintbronp
Received and filed
::feb 5 "
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIEDIU^
WIDOWEir'
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of Robert Frederick Edwards.
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
Occupation: h.o.us.e.work
(Kind of work done during most of working life)
14 Industry
or Business:
..Dvm... home...
15 Social Security No.
..none..
16 BIRTHPLACE (City) ._
(State or country)
..Gotenberg
Sweden
17 NAME OF
FATHER
Benson-
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
SwedeiL
19 MAIDEN NAME
OF MOTHER
unable to obtain.
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Sweden
" Informant ....Mts-p- EdwaTd A w AndersoE.-
(Address) Beal St . Wi
(Official Designation)
at a satisfactory/Tstandard certificate .of death
“ the/^rial or /^ansit permit was issued:
of Agp^ ^ Board of Health or oth«) ^
4
(Date of Issue of^ermU) v
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING iL: “...L;..
ORGANIZATION AND OUTFIT
SERVICE NUMBER ....
. ' • ■' \ ■ \-
RULES OF PRACTICE
.7'
,7)
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 pt^ rj
related to any form of injury. f LU
(2) Bosu'd of Health physicians will certify to such deaths only as those m
persons who, though disabled by recognized disease unrelated to any form pf
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.
-5
0 f.1
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 g;iven up or changed, or if the deceas^ 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.
i[ R-301A
Auctions
J=OR
ICERTIFICATE
iTlvlng
pF DEATH
not mean
li of dying,
\\eart failure,
li'f. It means
|j. or compli-
ihich caused
\s, if any,
^ve rise to
ause {a),
he under-
luse last.
ms contrib-'
•ath but not
the terminal
dition given
> [Chapter 137,
^ |54, requires
It; to print or
•bt cause or
death on
.e ificates.
A
..SiiffjQlk.
(County)
_llnthrQD
(City or To’
Lown)
Qllfp 0Immnnmufalt4 of HlaHHarljuaftta
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.
No.-
2 FULL NAME
29
62_Hm,sldfi Avenue, _Wlnthrop -
Anna R» Cardoza (Riley)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 62 Hillside Avenue, Winthrop st
(Usual place of abode)
PHYSICIAN — IMPORTANT
j (Was deceased a
lU. S. War Veteran, »»
[ if so specify WAR) J.1LO --
(If nonresident, give city or town and State)
Length of stay: In place of death 20 years months -- days. In place of residence 20 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
February
(Month)
hr i960
(bay)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
,q60
June 7,195ii , 19 to Feb. 4
I Isst S3W herai ive on Feb . I4. 19 6q , death is said to
have occurred on the date stated above, at P » m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) GreneTali^ed carcinoma •^sis _
Due To
(b)
Ductal carcinoma of the ^eft
breast
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
none
INTERVAL
BETWEEN
ONSET AND
DEATH
1 yr.
trn
If under 24 hours
AGE -p-iYears J L Months -/
1. — Days
-Hours Minutes
yrs
Was autopsy performed ?_ bO
What test confirmed diagnosis clinical & laboratory
5 Was disease or injury in any way related to occup§,tion of deceased ? .n0
If SO, SP'
(Signed)..
(Address)-- JUBartlett.
M. D
te Feb. 4 I'^P
eWlnthrop CemeteryL. Winthrop
Place of Buri^ or Cremation (Titvorl
or Cremation * ' (City or Town)
DATE OF BURIAL -F-ebruary Stl^ 19 6.0
FUNERAL DiRECTORRlchbrd C. Kirby. Inc*
m ri -D_„ - ■ -
ADDRES:
pl? Bejinlngton Street, E, Bos
Received and filed.
5-1960
(Registrar)
8 SEX
Female
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED Hff,,
or DivoRCEDMarriea
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of-
(Give maiden name of wife in full)
-Manuel T. Cardoza
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
13 Usual
Occupation:
Housewife
(Kind of work done during most of working life)
At home
15 Social Security No...
m3--05-53.Q4
16 BIRTHPLACE (City).
(State or country)
-Ciiels^a^
ass«
17 NAME OF
FATHER
Bernard E. Rile.y
C/}
H
18 BIRTHPLACE OF
FATHER (City)
Chelsea
2:
(State or country)
Mass .
w
<
19 MAIDEN NAME
OF MOTHER
Mary Lake
0,
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
He wf ouhd 1 and
Informant Mr • Manue 1- C ar doza -lius •
(Address^^
w., Hillside Ave», Winthrop =
I HEREBY CERTIFY that a satisfaof^y standard certificate of death
fi 1 e hnx'M/ox transit permit was issued:
Board of Health or
(Official Designation)
(Date of Issue of ermit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phx-sician or re<?istered 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. w’here 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 decea^. to the best of his knowledge and belief, sep’ed in the
army, nivy 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 primar>' and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any proxasion 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 '‘w'ar” 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
serxnce of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bur>* or otherwise dispose of a human body
in a tow'n. 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 cemeter>' to another, or from one grave or tomb
other than the receixnng 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 tow’n from which it was
removed w'ithin 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 serx'ed 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 w’hom the permit is so given and the phy’sician 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 re<juire.— Chap. 1 14. Sk. 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 too)ccupation, 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 hutnaq body or the ashes thereof
w’hich have been brought into the commonwealth until he has received a permit
^ 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
cemete^ or burial ground in which the interment is made.
. . . (^hap. 114. &c. 46. G. L.. (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws 6^11S'(Drtheobservance of the follow-
ing rules of practice: \ •
(1) Attending physicians w’ill certify to Such d^^th^only as those of persons
to whom they have given bedside care during a last il^hess from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only aS those of
persons w’ho. though disabled by recognized disease unrelated to any form of
injury, have died w’lthout recent medic^»^^(iar^ (ff yPtros^physician is absent
from home when the certificate of deatn iffTrceded.li * u l L i
(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 per^n aged 10 years or over. If the occupa-
tion had been given up or chan|;ed. 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
R-301A
■ UCTIONS
l^OR
^CERTIFICATE
■'iving
JjF DEATH
t>t enter
:han one
for each
b) and (c)
*.s not mean
oj dying,
•‘tart failure,
]<c. It means
' , or compli-
}tich caused
Its, if any,
jve rise to
attse la),
\he under-
jiiMe last.
'ons contrib-
•ath but not
the terminal
dition given
I
hapter 137,
ffi>4, requires
<•' to print or
th| cause or
I death on
cetlficates, and
■ f^8. Acts of
rAtires Physi-
to fint or type
' signature.
9-925686
i
(Thr (Hornmnnutpalti) nf lHaHaarI)UBrlta
Suffolk
(County)
)0 Viinthrop
lui
(City or Town)
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.
30
No .....MayflpWer„..N _ St.^^^- a hospital or institution.
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME..
..J.s.ssie B (Tom^^ lu's^warv''* “
(If deceased is a married, widowed or divorced woman, give also maiden name.)
eteran,
[if so specify WAR)
(a)
Residence. No ^.2.....PmSP.eC t,. AVS
(Usual place of abode) ^
Length of stay: In place of death years months
.St.
(If nonresident, give city or town and State)
days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Februaxy
( Month)
h»
(Day)
196q
(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
Not. 5 > 1950i9 ta...... , F.e.h... A, 19 60
8 SEX
9 COLOR
Female
V/hite
I last saw hQ.X*alive on Ji* I9...0C!.., death is said to|
have occurred on the date stated above, at .
,.a«.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Broncho pneumonia
(a)
Due To,
(b) IfyBertensiva JSt. arteriosclero tip
heart disease
Due To generalized arteriosclerosis
(C)
OTHER
SIGNIFICANT Bilateral cerebral
CONDITIONS
INTERVAL
BETWEEN
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED v/idow
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of ...M.by. .D .Hank^
(Husband’s name in full)
(_(jive majden name of wife in full)
ink] ^
ONSET AND '1 H IF STILLBORN, enter that fact here.
DEATH
1 weel AG ^.3 ..Years.3...
9 yrg
Jllyra
..Months...^3 . Days
If under 24 hours
Hours Minutes
13 Usual
^cupation :
..^9.b:Se;wife
(Kind of work done during most of working life)
or Business; . At....EQm.e..
IS Social Security No. Q2.8.-10.-T.9195:
16 BIRTHPLACE (City) ...i:f.-i:;Y.®.PP.P.9.4.....„..
(State or countp-) England
Was autopsy performed? b ii
What test confirmed diagnosis? Q?:^.P?rP.®:X....^....l^bpratOry I
5 Was disease or injury in any way related to occupation of deceased? nO
If so, specif'
M. D.
(Signed)
M.« . Tra.unate.inrii.Jr..>
, 73 6 ,q 60
6 i!V.in.thr.Q.p. ivinthrop....
Place of Burial or Cremation (City or Town)
DATE OF BURIAL Feb, 8
17 NAME OF
FATHER
Yiiilliam B Tompson
18 BIRTHPLACE OF
FATHER (City)
(State or country) England
19 MAIDEN NAME
OF MOTHER
Janet Duggan
20 BIRTHPLACE OF
MOTHER (City) ^
(State or country) England
60
^ FUNERAL DIRECTOR .Howard ,.S. . Reyn
ADDRESS i|VJji.t]hrp,p..._ Mass..
Received and filed rr.n.
OCNl 19
Ft
Do 1
(Registrar)
Informant ...S..U.y..i..e.....M.C.N.e.ll. -
(Address) 3? Pro.srip.ct Avs. V.'inthg-Op-
I .HEREBY CERTIFY tjiat a satisfactory standard certificate of death
filed with m^^EFO^ the burial or transit permit was issued:
^ ^
^ ' f '^Signatur^oi Ag^t of Board of Health^,;^oyiW ^
,
(Official Designation)'
(Date of Issue of Permit)
K
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfilment 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 The text goes on. The rest is in the file.