The volume, 1961
Town Clerk, Winthrop · from the Internet Archive · 540 pages · 33.1 MB
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ORM R-301 A
INSTRUCTIONS
FOR
EDICAL CERTIFICATE
In giving
(USE OF DEATH
do not enter
more than one
cause for each
if (a), (b) and (c)
This does not mean
’ mode Of dying,
h as heart jailure,
henia, etc. It means
■ disease, or compli-
ions which caused
ith.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib- -
ing to death but not
dted to the terminal
ease condition given
(a).
I ote:- Chapter 137,
ts of 1954, requires
ysieians to print or
>e the cause or
jses of death on
ith certificates, and
apter 48, Acts of
■9, requires Physi-
ns to print or type
ne under signature.
50H-11-59-926662
(County)
(Enmmntiuipaltlj nf MaaBarijuarlla
JOSEPH D. WARD
T. SECRETARY OF THE COMMONWEALTH
7 731 VISION OF VITAL STATISTICS
2 FULL
To be filed for burial permit
with Board of Health
or its Agent.
sp _ 3IHINUMRU 4
\£/r' CERTIFICATE OF DEATH Registered No I
Ia / , At — ■ r tS j I f * AA A . J . a/ -r'l/ X/a A- t/TT^t/i- / f (If death occurred in a hospital or institution,
No. /y / /V j. // f\ .() . J¥\.AA. U/y ../!... /..y'.... f/.PCSr' ''' hot. ( give its NAME instead of street and number)
-- sL, v / a / PHYSICIAN — IMPORTANT
N»ME,r/f /£ vjtiTe.it hmz/fa) A ram z R
,(If deceased is a married, widowed or divorced womanigive also maiden name.)
JA ¥ S V AM '/V IMjSaAL
* of abode) •
{(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. N
(Usual place of abode)
(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.
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
(Month)
(Day)
IWf
4 I H
E B Y C E R T I F Y , That I
v,sj^o dmL
I attended deceased from
V- W
I last saw h0j&iive on .?/... hCZ....~ 19 ..(o../., death is said to
have occurred on the date stated above, at ^ '77 / m.
INTERVAL
DEATH WAS CAUSED BY: IMME MATE CAUSE
(a) l /-J.
ONSET AND
• DEATH
(Db)c ti£££es'T-al- Ace?
(Dc)e ToA&T£&m 'SeLt^c rue r fty/’&Z-
/ttrfrtr D/s c c^j^a.
frYRy
OTHER
conditions fij' 1/T^hS
Was autopsy performed? ./.Y.
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased^
If so, specify
(Signed)
QAitf /V •
(PRINT OR TYPE SIGNATURE)
(Address) ^ Date.
6% c.u,c La^ &k.n dc
, M. D
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL ...!. 19-
FUN I^AL DIRECTOR 4..?
ADDRESS ~
f 'b £.* HAs>.£!!. VA..\.b.V fbJ.A L.Avu R£*iCc
Received and filed .Q 4.s....^.i 19.
"3 IbvH"
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
ITr*/ /\Le 'Ai vT £
10 SINGLE (write the word)
MARRIED . -
WIDOWED 'vAIVOCvUr.o
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
' (Give maiden name of wifejn-iull)
(or) WIFE of ...k.«H.LS: )< A A W. 3.
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE ^.^.Years...V^ Months.. ..hi ...Days
If under 24 hours
Hours Minutes
13 Usual . WCO'b^VvuFt
Occupation: .! .T!f : ;
(Kind of work done during most of working life)
14 jrtBx,, j&xbtM M,»„g..e..
Social Security No .fci. .0 .}>L Ll.
16 BIRTHPLACE (City) ...
(State or country)
TA A
17 NAME OF U c o ^ „ . -t- — * ,, . _ ‘ _
FATHER \ £ idlmt;' £^s.
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
C-3 £ «. VA A M -<
19 MAIDEN NAME
OF MOTHER
rAA^e Ha si
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
H A H
Alt sbt. TfiiCMMties.
(Address) I QaR Kn flLl jj).. |Vl C T £LM
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed wiprTjle BEFORE-ythe burial or transit permit was issued:
.CL. a*.
(Signature of Agent of Board of Health or other)
.2-1 IA. 6.../....
(Date of Issue of/Permit)
l/J
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
.....
XQkfc
. .. - 'I
■V. I>. -i v> .
.....A.....
r-V y\
J- i S /— » v . ~p
.....u...
bb* .b,:^
The fulfillment of the purpose of these laws calls for the obseq
following rules of practice:
(1) Attending physicians will certify to such deaths only as the
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 deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook-
hotel, etc. For a person who had no occupation whatever write none.
FORM R-302
S'
5^7
■*-’ v .
o-a .
^ *1
£ v~*
if".
r**
“ c a
•s-jg
U su
•So#
'•35 co
SJT
T3 >.*0
a £ v
•aTZu
A w u
- 3
^ ^ c
*OT5 O
S-mX
^ = «
sif-S
5-^J!
c .S
* of
o- S
>>05*5
.- c
w c o
i&E
3 g~
O M
5 c *
6 sc -5
J5 «m
c u
*.££
o «
at x
»*C S
3 O C
£ « S
_ £ *
A
Middlesex
Everest'
(City or Town)
Whidden Memorial Hospital
(Hlfp (ttnmmmuBfaWy nf UlaHBadjufifttB
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Everett
(City or Town making this return)
Registered No.
2
No..
..St.
[ (If death occurred in a hospital or institution,
| give its NAME instead of street and number)
on.„T,xT*«u. Berenice A (Nickerson) Goodwin c
2 FULL NAME !?. ) (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) jU. S. War Veteran.
15 Willow Ave. ^inthrop i b<Masi iVARl
(a) Residence. No..
(Usual place of abode)
Length of stay: In place of death years months f.days. In place of residence ySars months days.
13
...year
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
January 5 f 19.61 _3X
(Month) (Day) (Year)
$&$V.E30
c e ;
deceased from
6^FYJaatda[iTn5d,
19 _.... to.._ 19
I last saw h.®5live on .. 19 death is said to
,3 s $5 P,
have occurred on the date stated above, at ..# irm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Carcinoma of* Pancreas
(a)
Due To Secondary Carcinoma
<b) o'f""LTver
Due To
(c)
Acute Dilation Heart
OTHER
SIGNIFICANT
CONDITIONS
-NO-
interval
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
.Clinical Findings
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
(Signed)
John Y. Williams
M. D.
Everett 1-6
(Address) Date 19'&t.
6 Woo d lawn Crematory Evere 1 1
Place of Burial or Cr. ^^yjn a -py Cjj (City or Town)
DATE OF BURIAL 19.,
NAME OF Howard t> Reynolds
FUNERAL DIRECTOR WinthTOp , M*SS *
ADDRESS
Received and filed FE8 I335HI '.71.. ........
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWED JJ-idoW
or DIVORCED™ -LLLL/ W
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Ben j amin F . Goodwin
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
>2 78 3 18
AGE Years Months Days
If under 24 hours
Hours Minutes
13 Usual Teacher (retired)
Occupation: !r
( Kind of work done during most of working life)
14 Industry Public SChOOl
or Business :
15 Social Security No.
None
16 BIRTHPLACE (City)
(State or country)
mz liiM
17 NAME OF
FATHER
James Nickerson
18 BIRTHPLACE OF
FATHER (City) . NOVS SCOtlU
(State or country)
19 MAIDEN NAME
OF MOTHER
Adelia Garron
20 birthplace of Nova ScotiaT
MOTHER (City)
(State or country)
Informant
(Address)
Etta G. English
Wlhthrbp
A TRUE
IE COPY wWl (A ^ ,
5T :
ATTEST:
DATE FILED
(Registrar of City or Town where death occurred)
January^ 10 ,
.19
51
i .«• (/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ORM R-301A
b d
INSTRUCTIONS
FOR
EDICAL CERTIFICATE
In giving
iUSE OF DEATH
do not enter
more than one
cause for each
f (a), (b) and (c)
Chis does not mean
mode oj dying,
h as heart failure,
henia, etc. It means
disease, or compli- ^
i ions which caused
I th.
Conditions, if any,
ohich gave rise to
hove cause (a),
tating the under-
ying cause last.
t Conditions contrib- .
ng to death but not
ited to the terminal
•ase condition given
(a).
ote:- Chapter 137,
s of 1954, requires
/sicians to print or
the cause or
ses of death on
th certificates, and
ipter 48, Acts of
9, requires Physi-
as to print or type
ne under signature.
50M-U-59.926662
1
Suffolk £ VjS
(County)
Winthrop
(£nmmmiw?altf| of
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.
3
Registered No.
(City or Town)
no. .Mount’s Convalescent Home s, i^M^nlSei W^tor, j
PHYSICIAN — IMPORTANT
, full name Mary. A. Murray isrr no
(If deceased is a married, widowed or divorced woman, give also maiden name.)
. War Veteran,
[if so specify WAR)
o no. 25 White St. s, Ea?“ TTor.ton
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay : In place of death years .w^... months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January
(Month)
"57
1961
(Day)
(Year)
4 I H EREBY CERTI F^Y , That I attended
:.J....CC..tcfc^Ler. 19^...^L to ...^.Qt?L....Q.....
I last saw h.’S^alive on T} C .
have occurred on the date stated above, at ...fp?,7.$./..^....m.
19..',
deceased from
19.6-f.
death is said to
8 SEX
9 COLOR
female
white
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
a) Q....e (J..Q.t5...^.k..£c^^....
fr s' S’ i-7 a *
T
Q—-? -g c j / t Q
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
1M...
INTERVAL
BETWEEN
ONSET AND
DEATH
/ C
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
Gre/:orie
.Mgtasii
Wi/f
(Address) Date .’. 19.
;';;ho.ij cross i-iii^cn
Place of Burial or Cremation JS,1T» j) (City or Town) f.,
DATE OF BURIAL 19
7 NAME OF
FUNERAL DIRECTOR ...
ADDRESS
Frederick J. M.a.sra..t.h..
-Ea.s.t Bos-t-on
Received and filed
19-
(Registrar) p
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
w/doweV ldo vr ed
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
James F. Murray
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 04
AGE.TL Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: ....
be
ind oftyontoone during most of working life)
14 Industry
or Business:
woi
own Ho nre
15 Social Security No.
16 BIRTHPLACE (City) FJOVa- SCOtia
(State or country)
17 NAME OF
FATHER
And rev:
Cameron
18 BIRTHPLACE OF
FATHER (City) ....
(State or country)
Nova Scotia,
19 MAIDEN NAME
of mother Elizabeth Morrison
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
'Nova Scotia"
21 J ame s K . Murray
(Addresp 260 Revere St"; Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
1
„ (Signature of Agent of Board of Health or other)
i i..L£tA..i.
(Official Designation) (Date of Issue of Permit)
X
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 pessons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or. poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework. ^
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook-
hotel, etc. For a person who had no occupation whatever write none.
r/V
RM R-301A
X
iV”
V
Ay
NSTRUCTIONS
FOR
CAL CERTIFICATE
In giving
SE OF DEATH
lo not enter
ore than one
use for each
a), (b) and (c)
i does not mean
mode of dying,
as heart failure,
ia, etc. It means
sease, or compli- p
t which caused
ditions, if any,
h gave rise to
te cause (a),
hg the under-
cause last.
onditions contrib- .
to death but not
to the terminal
condition given
Chapter 137,
if 1954, requires
cians to print or
the cause or
i of death on
certificates, and
er 48, Acts of
requires Physi-
to print or type
under signature.
V/
CS
V
V1-6-S9-92 5686
Qtyr (Cmnmiitiuipalth nf JflaaflarfjUBrttH
< Suffolk
\ld
]Q
(County)
° Wlnthrop
JOSEPH D WARD
I SECRETARY OF THE COMMONWEALTH
\4 DIVISION OF VITAL STATISTICS
# M
STANDARD
To be filed for burial permit
with Board of Health
or its Agent.
(City or To«nfl|\i \1 ♦
. F*'*- si T i
46 Washington Ave
No. ...
, CERTIFICATE OF DEATH
Registered No.
■t
St.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME..
PHYSICIAN — IMPORTANT
f(Was deceased a
( U. S. War Veteran,
! if so specify WAR)
Selena Waterman ( Bennett )
(If deceyed is a married, widowed or divorced woman, give also maiden name.)
46 Washington Ave . St Wlnthrop
(If nonresident, give city or town and State)
la) Residence. No. TV Washington AV6 .
(Usual place of abode)
Length of stay : In place of death years
"
months
m
days. In place of residence years. . months days.
MEDICAL CERTIFICATE OF DEATH
DATE OF /'/■>*, V / G/ /
DEATH L.Z.S.J....
(Month) (Day) (Year)
4f I HEREBY CERTIF Y^_ That I attended deceased from
W.U..K....... ivAl'., to ALshnuJX. TJ i9«^ ...
I last saw h..fc’.J'alive on ..AfA.Qc. y^..J. !Z. .... 19 death is said to
have occurred on the date stated above, at .../..(?...:..efihr...l[f....m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
C^..<Z..Zr...a...i.JG..J0. irt?...M...A^..£. JLsk
( ov }
(a)
CbT JlCh...CL.m...D....&. 1.
CL
^ // £1 /c- cl
Due To
(c)
OTHER , ^ „ r- -
SIGNIFICANT ■
CONDITIONS . -y ^
CULdt
rnred ? .1/1
INTERVAL
BETWEEN
ONSET AND
DEATI
U/-
DEATIL
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRiEi^idowed
WIDOWEI
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Edgar CB r'lfeWm&tf
(Husband’s name in full)
full)
421
Was autopsy performed? £U> - -j. -
What test confirmed diagnosis? C.£...L..]c..i/...//^.f
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
M. D.
(Signer
/ J /ft , / < r
~y( (PRINT OR. TYPE^ic NATURE)
(Address) :/..A...£ LpX Jte...^.^j^iStoate..Z..rr..../f.
e Wlnthrop Cemetery, Wlnthrop
Place of Burial or Cremation
DATE OF BURIAL
imation _ _
Jan. 10,
(City or Town)
.60
7 FUNERAL DIRECTOR ... Ernest P. Cagglano
address 147 Wlnthrop St Wlnthrop
11 IF STILLBORN, enter that fact here.
12 Q7
ACE Years Months 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
15 Social Security No.
16 BIRTHPLACE (City) Cape Breton
(State or country) Canada
17 NAME OF
FATHER
Henry Bennett
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Cape Breton
Canada
19 MAIDEN NAME
OF MOTHER
Young
20 BIRTHPLACE OF
MOTHER (City) V®rP6 0.1*6 tOIl .
(State or country) Canada
21
Informant
(Address)
Mrs Doris Glllis
3*1*7 Qua
I HEREBY, CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
Received and filed
JAN 1 <> 1961
(Registrar)
"" — Ture of Agent of Board of Health or other)
y . C?r
(Official Designation) / (Date of Issue yn Permit)
UJ- 1/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
0£h;-:
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice: 'V
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a la-st illness frbm disease un-
related to any form of injury. f \
(2) Board of Health physicians will certify to sucfi-tkaths .'bnly as those of
persons who, though disabled by recognized disease ynttia'tiii’ to any form pf
injury, have died without recent medical attettdau'ee_or( WhtTse .physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certily' toj gfl dgaths 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 injurtl mj yifictfqij frdlajterfM occu-
pation, the sudden deaths of persons not disablW'By'r**°&m*?y<^®'s”se, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
u
3RM R-301A
INSTRUCTIONS
FOR
)ICAL CERTIFICATE
In giving
JSE OF DEATH
do not enter
more than one
:ause for each
(a), (b) and (c)
his does not mean
mode o) dying,
as heart failure,
’nia, etc. It means
disease, or compli- -p.
ns which caused
h.
mditions, if any,
hich gave rise to
ove cause (a),
iting the under-
ing cause last.
Conditions contrih-
to death but not
ed to the terminal
se condition given
>)■
te:- Chapter 137,
of 1954. requires
icians to print or
the cause or
ts of death on
1 certificates, and
'ter 48, Acts of
requires Physi-
» to print or type
under sijffature.
OM-H-59-926662
ullj? of fHaafiarljuartla
(3 £ 0 -S' S> o jL. /X'
(County)
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
j
'.o.
1 dv^TM/foP
lu (City or Town) /
1 No. WlJ/TM ft a Np Qa M/yj MA/J.Tyf ./iQSpi T»As, j
JLL NAMe/^/V /s/ I £• C (3 /? VY j£/? \ Coj+ E d
(If deceased is a married, widowed or cfirrtTced woman, give also mai
. J4/MQS ID & &
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL
den name.)
PHYSICIAN — IMPORTANT
{(Was deceased a
U. S. War Veteran, A )
if so specify WAR) £ y ..£?■
(a) Residence.
(Usual place of abode)
St.
Length of stay: In place of death years..
(If nonresident, give city or town and State)
,.months..^l!.3.days. In place of residence tZrtryezrs months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
TEN
(Month)
£1
(Day)
4Z
(Year)
4 I
jtjE R^E BY C E R^ IKY, ^^_^'atten^_deceased ^ojt
I last saw h. ve on . .., 1 death is said to
have occurred on the date stated above, at
8 SEX
9 COLOR
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) DEArn,
3
/bZtC-VUftL Ff 6&/USyT/ CKl -At/CC/HLjHfi
ro ^ 7~ZT~IZ -mjs v / /-TK / 7*
SIGNIFICANT %T / c i^r a
CONDITIONS J)l/r/3£TNZ 71/ i 7H/cJ>
INTERVAL
BETWEEN
ONSET AND
Was autopsy performed? /n
What test confirmed diagnosis? , &./rl./Xl<E.Ar.!k...r.
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signed)
Aiy/Z&jj
M. D.
15:,
r< r a . /H
(PRJNT OR TYP& STGNATURE) s /
(Address) E/.IlZ... V#./....
Place of Burial or CremaHjaw — > (City or Town)
DATE OF BURIAL 33U&C % : 19 Ll
....... 37 i ^ — \ “
ADDRESS
Received and filed
*^-4^Regi
Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED , - -f>
or DIVORCED U-
10a If married, widowed, or divorced
HUSBAND of
(Give maiden namejjf wife in full)
(or) WIFE of
— » (Give maiden name^qt wile in lull)
•>5 <?.$..€.^. CErsStEY
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
^^T.Years. JLl ...Months... /i
..Days
If under 24 hours
Hours Minutes
13 Usual //
Occupation : 4^r. . /. /"7. . . .Cr. . . .
(Kind of work done during most of working life)'
14 Industry
or Business :
/?T
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
f \ u S-fS/7
d l V/r
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
19 MAIDEN NAME _
OF MOTHER
6
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country
y) )\car/?7
Informant
(Address)
)di&
e bjfrial 6r transit permit was issued:
I HEREBY^ERTIFY that a satisfactory standard certificate of death
was filed
Signature of Agent of Boapd of Health or other)
ZLjZ
(Official Designation) yTDate of Issue of Permit) v/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF. DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
cO'l V 1 1
RULES OF PRACTICE
The fulfillment of the purpose of these laws
following rules of practice:
(1) Attending physicians will certify to such deaths
to whom they have given bedside care during a last
related to any form of injury.
(2) Board of Health physicians will certify to such deaths onhj
persons who, though disabled by recognized disease unrelated
injury, have died without recent medical attendance or whose
absent from home when the certificate of death is needed. "
(3) Medical Examiners will investigate and certify to all deaths suppOSal)t$'
due to injury. These include not only deaths caused directly or indirectly. b>*
traumatism (including resulting septicemia), and by the action of jcJJ
(drugs or poisons) thermal, or electrical agents, and deaths followin' *
but also deaths from disease resulting from injury or infection relat*
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
/ Mr ifiXL i'v/ '.
calls for the obaitrv&hce
Jrl ~ ' >>
oniy as-those'.ty pexkjms ( ,F
illnessTfoki rttelyase'un-A' » ,
€
Statement of Cause of Death. — Physicians:
on face side of standard certificate of death.
see explanatory instructions
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
KM R 301A
uty? (ftummnnuipaltlj nf Hlaafiarijuaptta
ISTRUCTIONS
FOR
:al certificate
In giving
E OF DEATH
o not enter
>re than one
jse for each
.), (b) and (c)
does not mean
tode of dying,
is heart failure,
a, etc. It means
tease, or compli-
which caused
litions, if any,
h gave rise to
cause (a),
* g the under-
cause last.
nditions contrib- .
o 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
*.r 48, Acts of
requires Physi-
:o print or type
inder signature.
"t
-59-925686
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
.TIFICATE OF DEATH
2 FULL NAME
L-
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
e
J (If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also 'maiden name.)
PHYSICIAN — IMPORTANT
((Was deceased a
■A U. S. War Veteran,
[if so specify WAR)
(a; Residence. No.
(Usual place of abode)
.St.
Length of stay: In place of death..
(If nonresident, give city or town and State) *
..years months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(»
4 1
E R E B Y
V S
fh)
E R T I F
19Sf*^” to..
/<?&/.
(Day) J (YeaO
That I attended deceased from
S 19 4* /
I last saw h.H^alive on Vjf AT. 7 J9 £/ ., death is said to
have occurred on the date stated above, at J? ..Ar,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
CM£MAL £€MjMUOtS£-
(a)
(b)
Due To
(c)
SIGNIFICANT "P /A T&S
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
3 res
Was autopsy performed? M<> L- ,
What test confirmed diagnosis? CA'/Y'C&L
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
(PRINT OR AS? SlGNATUR?)
(Address)
M. D.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
^4
9 COLOR,
10 SINGLE (write the word)
MARRIED
WIDOW Erf
or DIVORCI
10a If married, wi
HUSBAND of
(or) WIFE of
ved.^tT divorc
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
19 MAIDEN NAME
OF MOTHER
(Offi
MC
olal Designation)
.^L, . .
■djif Health or other)
A , * O/
(Date' of Issue of Permit^
f'X
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
rank, rating 1:.::
ORGANIZATION AND OUTFIT
SERVICE NUMBER
-X-
;#v*
‘ /X r(‘ " Uy ' P. Src
RULES OF PRACTICE .
7/ /l.r[ !'P.A ’>
The fulfillment of the purpose of these laws calls for fhe-.<ibA6rvamce of the
following rules of practice: r\<
(1) Attending physicians will certify to such deaths only as those ofu>erApn;;-
to whom they have given bedside caie during a last ill«e&fc fjorfi JOf-sN HPT
related to any form of injury. JRTt ’
(2) Board of Health physicians will certify to such deaths only as t.hos.e -of
persons who, though disabled by recognized disease unrelated to aoy form 'qf
injury, have died without recent medical attendance or whose pfiysjpian is.
absent from home when the certificate of death is needed. _ ■ a
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly ,6r Indirectly by
traumatism (including resulting septicemia), and by the actioj^ iji chemical
(drugs or poisons) thermal, or electrical agents, and deaths following- aljortipb,
but also deaths from disease resulting from injury or infection t^lortd'fo/dtctf-) /S'
pation, the sudden deaths of persons not disabled by recogniied' diSctfsfcj1 an<l , •
those of persons found dead. '/ \'J'^ j ■ , . \ p *s.V
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
JAM 701961 M
Statement of Occupation. — Precise statement of occupation is .very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
M R-301A
iTRUCTIONS
FOR
\L CERTIFICATE
n giving
S OF DEATH
not enter
re than one
se for each
i, (b) and (c)
does not mean
ode of dying,
i heart failure,
etc. It means
; ase , or compli -p.
which caused
lions, 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
i ertificates, and
r 48, Acts of
equires Physi-
0 print or type
1 nder signature.
<S
k
1-6-59-925686
1
(Cnmmmuuraltlj of JllaaHarljUBPttH
2 Suffolk
(County)
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
if DIVISION OF VITAL STATISTICS
w
no On sidewalk at 143 Revere Street
Winthrop
(City or Town)
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
4
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME
James L . Butler
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
f(Was deceased a
T U. S. War Veteranprjj
(if so specify WARvJD.lu
N., 1*3 Revere Street, Winthrop
(Usual place of abode)
In place of death.. .2
St.
Length of stay:
years
months
(If nonresident, give city or town and State)
days In place of residence 2 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
4 1 HER E/lf
JtSL
GtrcT+IL...
Month)
LL
(Day)
(Year)
CERTIFY, That I attended deceased from
, to 19.4*/
I last saw h.%!£!fclive on 9. , 19./?/., death is said to
have occurred on the date stated above, at
ZZ/fT* r
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
C ArP6A'A-7?y L'
(a)
Due * a-7? y
(b)
ZC-L-4FT? or*?
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED II9T,r4.j
or DivoRCEDiKiarriea
10a If married, wi
HUSBAND of ....
d. or divorced
M. Ruggiero
(Give maiden name of wife in full)
(or) WIFE of
INTERVAL
BETWEEN
ONSET AND || 11 IF STILLBORN, enter that fact here
DEATH
I Husband's name in full)
cj -Q_
Vc=t^
12
50
AGE..PV...Years...37 Months .1
29
...Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Yard man
(Kind of work done during most of working life)
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? <9
If so, specify
M. D.
(Signed)
(Address)
6rioly gross cemetery, Malden
14 Industry . .
or Business: UXX
Co* -
15 Social Security No. ...028 *■*03’ "*'2^20
ml moTHPi apf sr*itv\
Everett ..
(State or country)
Mass .
17 NAME OF _ .
father Richard Butler
C/3
18 BIRTHPLACE OF
uatufp
H
(State or country)
B t f f
r • & » X •
w
Pi,
<
19 MAIDEN NAME
OF MOTHER
Annie Johnston
Ms
20 BIRTHPLACE OF
unTHiTP
(State or country)
P.E*L*
Place of Burial or Cremation
DATE OF BURIAL JaAU&Py
(City or Town )
14th 61
21
Informal
(Address,
Mrs* Theresa M. Butler -wife
iSj [ 4 ^••••Revere St;. Winthrop
7 funeral directoPI chard C* Kirb
Inc*
i.£.y.y.$
addres917 Bennington St* , I ♦Boston
Received and filed
JAM. . ....
(Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
.
(SigjnatVe/of Agept-of Roard of Health. or other)
U& , ILlTCl
(Official Designation) (Date of/issue of Permit)
\i » a /s
{f - -7 / A//<V
SPACE FOR ADDITIONAL INFORMATION ...
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
'£> V* eft , r
ORGANIZATION AND OUTFIT
SERVICE NUMBER
JAN 12 1961 AH
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 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 deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
tM R-301A
STRUCTIONS
FOR
AL CERTIFICATE
In giving
E OF DEATH
> not enter
re than one
ise for each
), (b) and (c)
does not mean
ode of dying,
s heart failure,
i, etc. It means
ease, or compli- p
which caused
itions, if any, )
ii gave rise to f
; cause (a), e
ig the under- l
cause last. )
nditions contrib- .
0 death but not
to the terminal
condition given
cal Exarai
ed Jurls-
lon
e:- Chapter 137,
of 1954. requires
icians to print or
the cause or
s of death on
certificates, and
ter 48, Acts of
requires Physi-
to print or type
under signature.
•60-928145
/X
lu Su.ffolk
I® (County)
)2 Winthrop
[< (C'W tffiHop Con
\s3 No. ..dA^ . -Pi-easant St .-
(Lift (Emnmmiuiraltlj of HHaasarfiuarttB
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
scent Home
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
...8..
St
f (If death occurred in a hospital or institution,
. ( give its NAME instead of street and number)
2 FULL NAME
PHYSICIAN — IMPORTANT
Florence MacKinnon luw?.
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Veteran,
[if so specify WAR)
No
(a) R(Sep,ace oiS£ Shi r ley S treet
..St.
abode) “ ' ’■ J ^ U1 u (If nonresident, give city or town and State)
Length of stay: In place of death years hf. months days. In place of residence.j^Q... years months days.
MEDICAL CERTIFICATE OF DEATH
3g£IfHOF. January 1.1 1*6.1
(Month) (Day) (Year)
4 1 HEREBY CERTIFY
^ ^ ^ u . ......... .x That I attended deceased from
19 to....vjU “Xax*.* ,
I last saw hvfc?l^aiive on , 19.. kt ... death is said to
have occurred on the date stated above, at Xjr§...y^,....m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ....jXlXt^. h£&...CM~.X.A.<ja.L /kA.flhni'l.kC..
Due To
(b)
£>4-? g-
ct rre tic s
C / ti'Ji S —
Due To
(c)
^ <2^s c ydl/^c-XL
r
OTHER r? . / p / ,
SIGNIFICANT U..y.iU..fi..$...I.X..<A/6..?..r. AY
CONDITIONS
-xh
INTERVAL
BETWEEN
ONSET AND
DEATH
TP
Was autopsy performed?
1<M?at est confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify'
(PRINT OR TYPE/SIGNAJURE)
(Address)
Y.iCrV... Date 19(
6 Wln.thro.p.....G.eme..te.ry 7/inthrop
Place of Burial or Cremation (City or Town)
January 13 19.61
DATE OF BURIAL
7 NAME OF T „ ( . . -i
FUNERAL DIRECTOR . AP..uhUr. ...J... .0. ...Ma lCy
address Winthrop .....Mass
m
Received and filed .^T*.*.T. ....'T...f~. „ . „ 19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED ,
or PIVOSJEJVs 1 g
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 AT
AGE*.± Years Months..
..Days
If under 24 hours
Hours Minutes
13 Usual _ i
Occupation : Ij.p.e..s.s.maj£.e..p ; ;
(Kind of work done during most of working life)
“ “biSU, c lo thins.
15 Social Security No.
Q..g..^.rlir..6.Z13:
i6 birthplace (City) G.pp.e Br.e..tc.n..., .......
(State or country) Nova bco^ia
17 NAME OF
FATHER
Dougal MacKinnon
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Cape Breton
Nova Scotia
19 MAIDEN NAME
OF mother Marga r e L Ma c.i^achftrn
20 BIRTHPLACE OF
mother (city) .G.ap.®....j3..r.e..ti.Q.n
(State or country) NOVR F\C‘. Cl T. *
Informant ^.I.B.a.h.d.ll.e M.a.cK.l.L.n.on
(Address) hhbSh 1 r 1 ay St. - W 1 nthroi)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial oy transit permit was issued:
ealth or other)
(Official
Xi.ax z/^/z/
:iai Designation) (Date of Issue of Permit) f
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
"Z-TIVT
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice: IA1I •' n mm
(1) Attending physicians will certify to such deaths only as those of pergpg^'J ) j 0 17 i M
to whom they have given bedside care during a last illness from disease un- •'JO I ‘ •
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 oi
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
>RM R-301A
INSTRUCTIONS
FOR
ICAL CERTIFICATE
In giving
SE OF DEATH
do not enter
tore than one
ause for each
a), (b) and (c)
is does not mean
mode of dying,
as heart failure,
nia, etc. It means
lisease, or compli ■
is which caused
nditions, if any,
ich gave rise to
nte cause (a),
ting the under-
ng cause last.
Conditions contrib- ^
to death but not
d to the terminal
;e condition given
).
e Chapter 137,
of 1954, requires
icians to print or
the cause or
9 of death on
certificates, and
ter 48, Acts of
requires Physi-
to print or type
under signature.
3M-11-59-926662
Suffolk
(County)
(Enmmimutraltfj nf fHassarljuarttH
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 A.J
Winthrop
(City or Town)
¥i.nthr.°P Community Hospital St.|(^^ NAMEln^dt^tri
No.
Emilie Mar tine Neison(Enholm)
2 FULL NAME
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death years months.....! days. In place of residence 4hears months days.
(a) Residence. No M. Temple Avg. St.
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF t
death Jan.
(Month)
11
(Day)
1961
(Year)
from
1961
4 1 HEREBY CERTIFY, That I attended dec
Dec* 30, i9 55 , toJan.* 11
I last sailieralive on ItT.1.1.” 19 P.ldeath is said to
have occurred on the date stated above, alO *15 A *iM *
8 SEX
9 COLOR
10
F
w
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic heart
disease
(a)
Due To
(b)
Generalized arterioscler-
osis
Due To u
(o None..
OTHER
SIGNIFICANT
CONDITIONS
None
iftr
INTERVAL
BETWEEN
ONSET AND
DEATH
2
yr
5 yn
Was autopsy performed? 4. ^ ^
What test confirmed diagnosis?
dN.o
5 Was disease or injury in any way related to occupation of
If so, specify
(Signed) / _
VI T.rauns’tein,, Jr*.,
(PRINTER TyFE
314 o^BusYness: OWIl.. .h-OItie .
M. IX
i-al
Place of Burial or Cremation
DATE OF BURIAL J.ai
(City or Town)
7 NAME OF
FUNERAL DIRECTOR1
address 17.4 'J.in.t/r.o.p. St..*. .Y/lntiir.o.p ,
mIli
PERSONAL AND STATISTICAL PARTICULARS
GLE (write the word)
married widowed
WIDOWED vv-L'-l'-’vvCU
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of ;
(Give maiden name of wife in full)
(or) wife of Victor Emanuel Nelson
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
S AGE^^ Years..ll..Months..2.8..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
VO vyc-
house. work.
(Kind of work done during most of working life)
15 Social Security No nOn©
16 BIRTHPLACE (City) A-Q.S.S.
(State or country) li OrWUy
17 NAME OF
FATHER
To4-
Enholm
18 BIRTHPLACE OF
father (City) No.rway..
(State or country)
19 MAIDEN NAM.. \\<X. W »'•’ v *
OF MOTHER i)nahl.£>„ to - ohtrad-rr-
20 BIRTHPLACE OF
MO’THER (City) ....
(State or country)
Norway
Informant .... Nils Victor Nelson
(Address) R Tpin-plp A vpmip t Vn.nthrop
I HEREBY CERTIFY that a satisfactory ^standard certificate «f death
was filed t^lTTne BEFORE the burial oty^ransit permit was issued:
mSS., rdL
ignatura
Health or other)
Received and filed
(Registrar)
(Official Designation)
(Date of Iss:
// n:UV
ssu€ of Permit) '
l/\
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
E
......
m -
RULES OF rR-ACT
^aiasun
The fulfillment of the purpose of these laws calls ’ tot* tVe'fc bV^rvari£e of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper— private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
)RM R-305
L
© ©
ES
Middlesex
(County)
Winchester
(City or Town)
Winchester
(City or town making return)
10
Registered No. .
Hi
m 8
P
*3
C'5
frvl
If
28
•=*o
31
1|3
i c-r
ih
S'cS
•EJS6
1:4
0« .
I 111
15
^g-c
■ 8
1&-L
3 o"
•S o f
Il-S
•» .tJ.fi
£ 6 c
3 c §
Tf"
V
it'
Etj O
111
i-So
°X»
8 8s
•sjfc
8 0*3
(CommanropalU) of HaBBatljUBPtta
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
Winchester Hospital I (If death occurred in a hospital or institution,
No St. \ give its NAME instead of street and number)
Dorothy M. Howe (Marshall) f
2 FULL NAME I (Was deceased a flO
. (If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran,
42 Floyd Street Winthrop,lifta§Sfify 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 months days. In place of residence years months days.
41 HEREBY CERTIPY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
tARD W infl uence
jf -'Suri tHt- ★ •Ether AnosttiFs tB'used' 'as
rnesthetic f or- ct nsure of petrfnratetf
:e.c.um...c.ausfi.d...hy. ...cancer.^
M
3 DATE OF
DEATH ....
[JD^.L^CERTIFI^ATE OF DEA
( Month)
(Day)
(Year)
S i
5 Accident, suicide, or homicide (specify)..
Date and hour of injury 19..
Where did
Injury occur?..
(City or town and State)
Did injury occur in or ahont home, gry j1™ in industrial place, or in public
place?
Manner of
Injury
Nature of
Injury
-ISncrafiLtyaF of place)
IHPSji&ilUHEy ocfctir?)
While at work? Was autopsy performed?
yes
6 Was disease or injury in any -way s»k»t,tLto occupation of deceased?..
If “• RSfrytv Benson
4A ,S4 ny'JUt
(Signe<f^0.^...i*.34.n...
inches ter
Cametery -No. mson
19
Place of Burial, or Cremation.
DATE OP BURIAL.
■AffredB. Marsh
i — i hr Town L-
19...,
8 NAME OF . - - - - — -
FUNERALiy^^T^thropSt.iWfn-fhropjMass.
ADDRESS
Received and filed £.0 ...Hiijiil
(Registrar of City or Town where deceased resided)
.19 .
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
imaTe
LOR OR RACE
11 SINGLE (write the word)
MARRIED m-. J o -(
widowed marr I 60
or DIVORCED
11a If married, widowed, or divtJIWSf1 —
HUSBAND of
A 1 ISirrt^fta Pter*f Hf*w^ull)
(or) WIFE of
(Husband's name in full)
12PP STILLBORN, enter that fact here.
AGE
..Years Months .
Days
Vl
under 74 hours
Hours Minutes
14 Usual
Occupation :
housew rk
(Kind of work dpne during most of working life)
IS Industry
or Business: FlOnf?
'mr
lone aun
h-.f>e
16 Social Security No t own
17 BIRTHPLACE (City) MgSS.,
(State or country)
is name 01Frar»c i s Joseph Marsha l
FATHER
19 BIRTHPLACE OP
FATHER (City)
(State or country)
Mass..
20 maiden name Charlotte Bearse
OP MOTHER
ftyannfs
21 BIRTHPLACE OF
MOTHER (City) MaSS
(Stat,
State pr country)
- ialler HQwe
Inform^ E. l.oyd S t . ,... W I H thT !'P.» ...M.3SS ....
■ -yujunj
(Address)
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
-17-61
DATE FILED ! 19..
,1 a y L
'I
[
Si
do
i
»
i
t
<:•
tfl
(in
ft.
lo
m
fir,
"I
V
»•:
' "V-, ’ ■ — TTT
RM R-301A
NSTRUCTIONS
- FOR
I CAL CERTIFICATE
In giving
SE OF DEATH
io not enter
l ore than one
luse for each
a), (b) and (c)
s does not mean
mode of dying,
as heart jailure,
ia, etc. It means
isease, or compli- ^
■which caused
Iditions, ij any, j
ch gave rise to I
ve cause (a), >
ing the under- l
g cause last. J
onditions contrib- ^
to death but not
If to the terminal
| s condition given
lie:- Chapter 137,
|)f 1954, requires
rians to print or
_ the cause or
of death on
I certificates, and
ler 48, Acts of
I requires Physi-
Ito print or type
under signature.
IM-11-59-926662
iw £±L/<
I A (County)
1 < U- ,
(City or Town)
No.
CEummomuraltli uf HHajaaarliuHftta
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
11
STANDARD
CERTIFICATE OF DEATH Registered No.
,—7 y \ij * r\ i/ c cr {(If death occurred in a hospital or institution,
4'.. St. \ give its NAME instead of street and number)
. PHYSICIAN — IMPORTANT
2 FULL NAME ^/a.M.CV. L UA.fi. V. IWs. WarTeleran
(If decease^ is a married, widoVed or divorced woman, give also maiden name.) [if so specify WAR)
(a) Residence. No 7A dj&Lnj&I. St ,
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years. months..:?...f>....days. In place of residence years.....^....months...?..?...days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January 16, 19.61.
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, That I attended deceased from
. April 27, 19. 60., to January .16, 19.61..
I last saw h .Slalive on ....JUnUa.ry...l6, 19 6l death is said to
have occurred on the date stated above, atlQ..8.13 a • m. INTERVAL
BETWEEN
ONSET AND
DEATH
85mOS«
8 SEX
9 COLOR
Ls h i -/■ t
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Iftrelomeningocele with
hydrocephalus
Due To
(b)
Due To
(c)
Sicant ^ominal ascites
CONDITIONS
3 wks.
Was autopsy performed? ....f"Y... .
What test confirmed diagnosis? .^^9^1.
5 Was disease or injury in any way related to occupation of deceased? tJP.
If so, specify
(Signed) M . D.
Ms 'h’aunstein, Jr...» M. H.
(PRINT OR tvVe SIGNATURE) '
(Address) ^ t Rd • Date.....J.Q-R.». 16,19.61.
Place of Burial or Cremation . (City or Town)
DATE OF BURIAL J.d.Al..:. Lk.., 19
UAJL.a.m. H.. Bvih.A.
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED C' ^ /<-
WIDOWED^ “dc<r I
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.. . £5 ...Years .^....Months.A.<?...Days
If under 24 hours
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) :..££.L^..£...hi...(^..O..f!....
(State or country)
17 NAME OF
FATHER
£zdh
,rV\ A ± j-
A /vi.
18 BIRTHPLACE OF
FATHER (City)
(State or country)
r I
S£,^A.f...£^....&..A:.
C C Y) YI
19 MAIDEN NAM^—5 r > t
OF MOTHER b l H T A C . K i I £ y
r>
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
fzlas >1
Vn A ss
_. io
(Address) 5 u cys /n r / n V % ^ W *1 / h ft. 6 \4
Informant
7 NAME OF
FUNERAL DIRECTOR
ADDRESS S.&...AL&..L6M 3.t^..AlAli,&.Al..i..
—7^-, — Jan il mf — 1 — - —
I HEREBY CERTIFY that a satisfactory 'standard certificate of death
was filed with me^BEFORE the burial or/transit -permit was issued:
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
ill
o
II
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
MOace side of standard certificate of death.
tatement of Occupation. — Precise statement of occupation is very impor-
_ it, so that the relative healthfulness of various pursuits can be known. Make
me entry in this section for every person aged 10 years or over. If the occupa-
'on had been given up or changed, or if the deceased had retired from business,
Jport the kind of work done during most of working life even if retired. Chil-
ren not gainfully employed may be returned as at school or at home. For a
. X>man whose only occupation was that of home housework, write housework.
j iiAh*or a person engaged in domestic service for wages, however, designate the
"**cupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
ORM R-304
In giving
CAUSE OF
ETAL DEATH
do not enter
more than one
cause for each
of (a), (b)
and (c)
Hal or maternal ,
ndition causing \
tal death ( do
use su c h l
rms as stillbirth}
prematurity .)
•fa/ and/or ma-/
rnal conditions, [
any, which gave 1
s e to above '
use (a), stating ,
e underlying'
use last.
inditions of fetus
mother which
ay have contrib-
e d to fetal
ath, but, in so
r as is known,
re not related
cause given
(a).
5M-6-60-928241
Suffolk
(County)
Winthrop
(City or Town)
(Ctmtmonfnealil] of ,iWaeaacl|usctts
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
CERTIFICATE OF FETAL DEATH
(STILLBIRTH)
To be filed for burial permit with
Board of Health or its Agent.
Registered INo.
no Winthrop Community Hospital, Winthrop
St.
j (If death occurred in a hospital or institution.
give its NAME instead of street and number)
name of fetus Premature Female Sera
(if given)
3 DATE OF y ney y oil
DELIVERY Jan. 17, lyol
(Month ) (Day) (Year)
4 SEX
Male FemaleX Undetermined
5 COLOR (if . .
determined ) W
6 THIS BIJJTH (Check one)
Single-A. Twin Triplet
7 IF MULTIPLE BIRTH, BORN :
1st 2nd 3rd
8
FULL
NAME
FATHER
Alfred D. Sera
residence, no. 105 Garfield Avenue street
city OR TOWN Chelsea state Mass.
10 COLOR OR
race White
11 AGE AT TIME O' „
THIS DELIV 37
MOTHER
14
maiden name Kathleen T. Griffin
present name Kathleen T. Sera
residence no. 105 Garfield Avenue
STREET
city or town Chelsea state Mass.
12 PLACE OF„ „ , ,
birth E. Boston, Massachusetts
(City or Town) (State or country)
occupation Accountant
16 COLOR or ....
race White
17 AGE AT TIME OF
THIS DELIVERY
35
(Years)
18 mRTH °! Medford, Massachusetts
(City or Town) (State or country)
19
informant Mother
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
(a) How many children are
now living?
(b) How many children were
born alive but are now
dead ? ^
21
LENGTH OF
22 WEI 'HT OF FETUS
... — »■—
23 WHEN.
DID FETUS DIE?
—
PREGNANCY
2 Lb. - Oz.
Before ./
L During Labor
6
mOS. completed weeks
(or Grams)
Labor
or Delivery
Unknown
(c) How many previous fetal
deaths of ANY gestation
afie? »
24 AUTOPSY
Yes
No
(a)
Due To (b)
Due To (c)
Placenta Previa
Premature Separation of Placenta
OTHER SIGNIFICANT
CONDITIONS
None
'26 U' 0. ffi cOdu: n*. t./~.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL / &y 19 <£, /
27 NAME OF
FUNERAL DIRECTOR
k.n . L>. U' ,gj,3 ,
ADDRESS */../..% /3 ?1. £>£. dU' C,/7.g)s CA.
Received and filed
(Registrar)
A TRUE COPY ATTEST:
I HEREBY CERTIFY that this delivery occurred on the date stated
above at 12:30 m#, and product of conception was not a live birth.
Signature of iding Physician or Medical Examiner:
(X-^C-A \\r^ . M.D.
A. Paul DerHagopian, M.D.
(PRINT OR TYPE SIGNATURE)
Address 39 Cary Ave. , Chelseaate 1/17/ » 6l
I HEREBY CERTIFY that a satisfactory certificate of fetal death
was filed with^jne BEFORE the burial or transit permit was issued:
(Official Designation)
EXTRACTS OF CERTAIN SECTIONS OF
ACTS OF 1960.
Section 2A. “Examination of records and returns of illegitimate births, or abnormal
sex births, or fetal deaths, . . . shall not be permitted except . .
Section 9 A. When a child is born dead, after a period of gestation of not less than
twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and
no movement of voluntary muscle, the physician or officer attending at the birth of such
child shall forthwith furnish for registration, at the request of an undertaker or other
authorized person or of any member of the family of the deceased, a certificate of fetal
death on a form which shall be prepared by the secretary of state as required by section
sixteen. Town clerks shall record certificates of fetal death in the town register of deaths
in the same manner as a death certificate, but they shall not be required to record such
certificates in the town register of births.
Section 12. “. . . No birth record of a child born out of wedlock or of a child of
abnormal sex, and no record of fetal death shall so be transmitted to any other city or
town.”
Section 2U. In any statement of births, deaths and fetal deaths printed by a town the
name of an illegitimate child or of its parents or of the parents of a child born dead shall
not be printed, but the word “illegitimate” or “fetal death” shall be used in place thereof.
A town violating this section shall forfeit to the mother of such child not more than one
hundred dollars.
M R-301A
It (RUCTIONS
! FOR
II L CERTIFICATE
it giving
ft OF DEATH
4 not enter
m: than one
e for each
(b) and (c)
\loes not mean
\de of dying,
heart failure,
etc. It means
isc , or compli- ^
which caused
ions, if any,
gave rise to
cause (a),
the under-
cause last.
litions contrib- _
death but not
o the terminal
ondition given
I Chapter 137,
Ijf 1954, requires
is ians to print or
■ the cause or
Bf of death on
thertificates, and
ii r 48, Acts of
■•equires Physi-
»i o print or type
Binder signature.
TN
K 1
O'
•1.0-928145
lu Suffolk..
I® (County)
.jf_lnjfc.br.Qp..
(City or Town)
<Smtmuimu?altf| of fUafiaarfiuaetta
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
No.
Wlnthrop Community Hospital..
{(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME
PHYSICIAN — IMPORTANT
f (Was deceased a
Mary A ... .Mc.Gll.ll cuddy us. w^vSe™, No
(First Name) (Middle Name) (Last Name) (if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Vl oh .
(a) Residehce.' t>Io.
(Usual place of abode)
59 :;.P1.^. Avenue
..St.
Length of stay: In place of death yea:
n
&
months days. In place of residence.. 5.Q. years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January 1$ 1961
(Month) (Day) (Year)
4 I
J E R E B E R T I F Y , That I attended deceased from
r/L% 19.4 /
I last saw Jj^Lalive on /....S..P...7j.. , V^.../...., death is said to
7 UXtts.
have occurred on the date stated above, at .
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
fl7? 0 A A a Pi' A ^EATH
Due To
<b> C/E^/E/3 7?' 4 4.
Due To
(c)
7~-fTt'7p /> aa 72'oT^T
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
ismzp
(Address)
, M. D
7A/ AAl^P
O'. If tz 6~
—I PRINT OR TYPE SIGNATURE) . / ,
7 .Date S/?P 19 A/
tfW&P
6 Win throo. Cemetery Wlnthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
January 23 i9..6l
7 NAME OF
FUNERAL DIRECTOR
Arthur J. 0 ’Maley
ADDRESS
Received and filed
W.l.n.t..hrpp..,.....Ma.3s.
19,
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
wi?i
or DI\
10a If married, widowed, or divorced
HUSBAND of .....
(Give maiden name of wife in full)
(or) WIFE of ..William H, McGill 1 cuddy.
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.
70
Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home..
15 Social Security No None...
16 BIRTHPLACE (City)
(State or country)
Everett
17 NAME OF
FATHER
William Harron
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER MSL PY J .
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
-Ireland
Informant
(Address)
Nanc
39.
Ii
McGi Hi cuddy
— nrtei
co'Xver; Wlhthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed witR^fne) BEFORE ihp-burial pi transit permit was issuejl:
,..f
Agent of Board of Health or other)
lir.
/ (Date of Issueydf Permit) /
e/ DtruKi
%:k.4ai
(Signaturq^bf Ag«
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
Ujvs_cal)s for the observance of the
'thfiUily as those of persons
The fulfillment of the purpose
following rules of practice:
(1) Attending physicians will _
to whom they have given bedside ca"re 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 9!
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury'. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
*M R-301A
STRUCTIONS
FOR
1 AL CERTIFICATE
In giving
OE OF DEATH
i not enter
re than one
Cise for each
I), (b) and (c)
does not mtan
[ odt of dying,
htart failurt,
ttc. It means
| ease, or compli-
which caused
l ftions , if any,
gave rise to
cause (a),
| g the under-
cause last.
editions contrib -■
death but not
to the terminal
condition given
Chapter 137,
f 1954, requires
Ians to print or
r !
Jhe cause
of death
ertificates.
or
on
L
/h
\w
1°
1 /(*
1°
(u
(«
\ J
'0,
2 FULL NAME-
Suffolk
cy <»
nt 'O
bounty)
op
(City or Town)
20 Lewis Avenue
No
Sty* (Emntttmmmiltty nf HJaairartyuafttH
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.
14
Registered No.
f (If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
Bertha Rosen
(If deceased is a married, widowed or divorced woman, give also maiden name.)
25 Parkman
[ PHYSICIAN — IMPORTANT
) (Was deceased a
) U. S. War Veteran, nO .
' if so specify WAR)
(a) Residence. No
(Usual place of abode)
Length of stay: In place of death . years.
St.
months days. In place of residence ....
30
Brookline, Mass*
(If nonresident, give city or town and State)
years months. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
January 201961
(Month)
(Day)
(Year)
I HEREBY CERTIFY, That I attended deceased from
Apr. 21, 106ft> to Jan. 18, iq 6l
i9_6l > death is said t0
er
I last saw h alive on
have occurred on the date stated above, at
A >
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(.) Carcinoma of the ovarium 1 yr.
metastic to abdomen
vr
~T~^
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?.
INTERVAL
BETWEEN
ONSET AND
DEATH
What test confirmed diagnosis? ..Clinical & cytologycal..
5 Was disease or injury in any way related to occupation of deceased ? .J1.0
Ernst mfovM.I),
(Signed)-
(Address)
ij
. P-L l ' l v _ _ m D
39 Columbia Road, Dorchester ’
— PatJan^JS-L, 19-6.1
6 Pride of Jacob, WxkI West Roxbury
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
January 22, 19 61
7 fun'eral d i rector Benjamin F.S ol omon
address 4?0 Harvard Street, Brookline
Received and filed
m 2-1 ft6!
(Registrar)
_.19_
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED WlClOWeCl
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of.
(Give maiden name of wife in full)
Joseph Rosen
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 68
AGE Years
Months .
.Days
If under 24 hours
Hours Minutes
13 Usual Housewife
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No..
16 BIRTHPLACE (City)
(State or country)
-Poland"
17 NAME OF
FATHER
Morris Rnspn
(O.K.')
C/3
H
18 BIRTHPLACE OF
FATHER (City)
Pol anri
z
(State or country)
W
<
19 MAIDEN NAME
OF MOTHER
(unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Poland
, Estelle Cohen
Informant-
(Address) 20 Lewis Avenue, Winthrop.Mass .
I HEREBY CERTIFY that a satisfaetdt-y standard certificate of death
was fil£ji '5>ith^me BEFORE the buinal or*transit permit was issued:
rd of Health or other)
^ S'/
(Official Designation) Date of Issue of Permit
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the ‘request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
l>est 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.
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. Sec. 45.
G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of pereons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. — General
Laws, Chap. 38, Sec. 6 , as amended by Chap. 632, Sec. 4, Acts of 1945.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. Xo 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 ppssession 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
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 Merk of the town where the body is to lie buried
or the funeral is -to.bq held, or from a person appointed to have the care of the
cemetery or burial £rbu$d ir\. Which the interment is made.
. . . Chap. 114, Sec. 46, G. LT, (Tercentenary Edition).
i-kl/LES OF PRACTICE
The laws calls for the observance of the follow.
(1) Atlerrdlijg-miysiciaHa Certify to such deaths only as those of persons
to whon^me/ hacy't'gi'^grfcgdsijectle u ring a last illness from disease unrelated
(2) Board phyaictervfovfill certify to such deaths only as those of
persons ‘who! Aijgph amsabletf^jy msc ipinized disease unrelated to any form of
injury, h^wi qifejl ^Jthout recgrmratdkai attendance or whose physician is absent
from homy whVi trf^2im^Wc~njrd<®tl‘i is needed.
(3) <(Ji\rest>gate and certify to all deaths supposably
due to injur^vfjlJtaagijjUalMAlfi^^o^ly deaths caused directly or indirectly by
traumatism t>^ljrXj«/5aiasp\fijre^septicemia). and by the action of chemical
(drugs or poisons)U3reffcUVoil»tectrical agents, and deaths following abortion, but
also deaths from disease resulting from in;ury or infection related to occupation,
the sudden deaths persons not disabled by recognized disease, and those of
pm< '"•MN24l96(-Af(
Statement of Cause of Death.— ^Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ORM R-302
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A
Essex p[*
(County) -’ f
Danvers
(City or Town)
(Enmmmuuraltlj nf Maflaadjuartta
JOSEPH D. WARD Danvers
Commonwealth ••■••”:•• ws»*.*.Jf..s?.*...«..„.
Secretary of the
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
J.
noDanvers State .Hospital., Hathorne .«. ("tJ“ihNAME"ta5,3 Xo!i^dn™S&
FULL NAME ... Elizabeth Colbert (Smith.)
(If deceased is a married, widowed or dive ced woman, give also maiden name.)
/(Was deceased a
)U. S. War Veteran,
\if so specify WAR, UQ
(a) Residence. No.... 7 Willis Avenue //. Kinthrop, ...Mass*
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death. 4 years. B ..monthsl.L..days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
January
(Month) *
21*
( Day f
1961
(Year)
I HEREBY CERTIFY. That I attended deceased from
)‘ay 11* 19 .5.6... to January. ...21* ..... » 61
I last saw ve on .... ilcLTllJLflry 2 1 } 19....(Slieath is said to[
have occurred on the date stated above, at 7 • 00a #m
female
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Art eriosclerot ic Heart Di 4ea se
od Generalized .Irteriosclerds is
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
years
years^
Was autopsy performed? yes
What test confirmed diagnosis ’ Q.Ut.QpS.y
5 Was disease or injury in any way related to occupation of deceased ?
If so. specify
M. D.
(Signed) Andrew ..Nichols III
.> Hathorne , Mass*..i>ate. 1/21/ 19. 61
(Address)
6 Woodlawn. Cemetery, Everett, Mass
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
January 24, 19...6l
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Ernest P . Caggiano
Winthrop*...Mass*
Received and filed MH 3 -0 1961 19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED . ,
or DIVORCED WldOWed
10a If married, widowed^pr divorced
JcosxsfxxKl* Benjamin-.. Arnold
(Give maiden name of wife in full)
(or) wife 0f2 * William . Colbert
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
79 Years.....?..
Months..*,
..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Waitress <1 Cook-Retired
( Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
[removed]
16 BIRTHPLACE (City)
( State or country)
Lawrence.
Mass.
17 NAME OF
FATHER
George Smith
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Lawrence,
Mass,
19 MAIDEN NAME
OF MOTHER
Mary Hopping
20 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Lawrence.
Mass.
21
Informant
(Address)
Mary E. Sheehan
Hathorne , Mass,
A TRUE
ATTEST
(Registrar of City or Town when
DATE FILED
ere death occurred )
January 2J5, 10 6l
TO viz
.• • . Vv.'.wu.v/| V
<’■'1 0 ^
i'r’if ^7 V V:t'
^yl 1,7*
^itiuys%yf r
■\ ' /l/ * /
JAN 301961 ah
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
VI R-301 A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
not enter
than one
for each
(b) and (c)
oes not mean
oj dying,
heart failure,
etc. It means
e, or compli- ^
which caused
ns, if any,
l| gave rise to
cause (a),
the under-
cause last.
aitions contrib
death but not
„ the terminal
ondition given
ft:- Chapter 137,
ta f 1954. requires
dans to print or
the cause or
of death on
x certificates, and
■ :r 48, Acts of
9 requires Physi-
fco print or type
jnder signature.
.o
\
0-928145
X
Sty? (Smmnnnuipalt^ of
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.
lu Suffolk
JO (County)
1 (ft
/u W.int.hr.a.p.
[O (City or Town)
|_1 70 TP-- j- 04- ((If death occurred in a hospital or institution,
'flu No UQ. O.V..« St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
Registered No.
1(1
2 FULL NAME EStOlle B.Q.mS.tein (uVS. WarTete^an,
(First Name) (Middle Name) (Last Name) (if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
..No..
(a) Residence. No 38 FomeSt 3t . St .Wl.nt.hPOp
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death 38
years months days. In place of residence .3.8 years months days.
MEDICAL CERTIFICATE OF DEATH
3 death0! January. 2. 3 1961.
(Month) (Day) (Year)
4 I
Ji EREBY CERTIF That I attended deceased from
C~ 19.^2$.., to...p*L ./. JiL3. i9.ir /
I last saw h£.T.alive on .. J..A.SSV , 19-. it. {., death is said to
have occurred on the date stated above, at ... ‘/'//S 4 j™-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ^ (0 y m ^ y,/ $444m-5-t-q\h Aentd
Due To
(b)
Due To
(c)
/I
J
$C' yghi v
/f{?u r {- »vs<2Af<
T
<L~
SIGNIFICANT (&%.£- tf. V fc>4 Y.£S..L.St.
CONDITIONS J \
Was autopsy performed?
What test confirmed diagnosis? (Q. l i & ./
5 Was disease or injury in any way related to occupation of deceased? Kf rj
If so, specify .... » *
INTERVAL
BETWEEN
ONSET AND
%H
/CM
t
U
)i y vs.
238, ©&= SIGNATURE)^
(Address) Winthrop. Date.... 1/2 3 .19.61..
Tii'ereth Israel of
6 Wint.hr.op
Place of Burial or Cremation
Everett
(City or Town)
DATE OF BURIAL January .24 I96l
7 NAME OF
FUNERAL DIRECTOR
Paul R ...Levine
address 470 Harvard St . , Brookline
Received and filed
JAN 24 1361
.19..
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
'White
10 SINGLE (write the word)
MARRIED w/r _ ji
widowed named
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Theodore Bernstein..
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
■ 62
AGE..y..e-....Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: Rouse-wife
(Kind of work done during most of working life)
“ S&m.: At...hQffl.e.
15 Social Security No.
16 BIRTHPLACE (City) .....
(State or country)
...Canada..
17 NAME OF
FATHER
Jacob Trattenberg
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
..Lithuania.
19 MAIDEN NAME
OF MOTHER
Pauline Geffen
20 BIRTHPLACE OF
mother (City) Lithuania...
(State or country)
21 informant Ih.e.Qd.o.r.e B.D.ms.t.e jm
(Address) Bo Forrest ot . . winthroe
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with^me? BEFORE U>e. burial or transit permit was issued:
“ 7 * '„:&..w..<g..:3Ladaar. — .. ■
Health or other)
..(Xa-Lj
(Signal y
(O
.JrL<Z....*
fficial Designation)
jJsLxLJl
ate of Issue of Permit)
i/.n\A
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
The fulfillment of the purpose ofjhgse laws <aUs for the observance of the
following rules of practice: * 1S%rM IQCI fill
(1) Attending physicians deaths only as those of persons
to whom they have given rare 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 tp all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
VI R-301A
A-
'RUCTIONS
FOR
L CERTIFICATE
jt giving
S OF DEATH
not enter
than one
e for each
(b) and (c)
toes not mean
ie of dying,
heart failure,
etc. It means
ise, or compli-
which caused
ions, if any,
gave rise to
cause (a),
the under-
cause last.
c litions contrib- -
death but not
the terminal
ondition given
I Chapter 137,
If 1954, requires
ians to print or
the cause or
of death on
ertificates, and
r 48, Acts of
I'equires Physi-
o print or type
inder signature.
C,
i
\& Suffolk
(County)
( tu
Wlnthrop...
(City or Town)
(Imttmmuitraltir at HlaBBarijUBFttB
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
No.
.4.2 Atlantic Street
St.
((If death occurred in a hospital or institution,
( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
((Was deceased a
2 FULL NAME Gr© O rg© J. Clara on
(First Name) (Middle Name) (Last Name) (if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
. j U. S. War Veteran,
(if
(a) Residence. No. . 42 Atlantic St. ,
(LTsual place of abode)
..St.
(If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence 22 ..years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
January ; J24f 1961
(Day) (Year)
4 1 HEREBY CERTIFY, That J attended deceased from
iM.., to £:.n. 19.il
I last saw h...»L. alive on .U..1..J3.., 24-* , 19 ., death is said to
have occurred on the date stated above, at -1- .p..jn.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Uremia ] DE*TH
Due To
<b> Arteriosclerosis
Due To
(c) r'Viv>^
i. L_
rn O - . ft
IX tl
significant c.e.r..Q.l3.r..e.l Hsifio.rrh.axie. 1
CONDITIONS
Col OKI
Was autopsy performed?
What test confirmed diagnosis?
-19J
INTERVAL
BETWEEN
ONSET AND
1946
-15-
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
(TR
<£>
OR TYPE SIGNATURE)
(Address/^^.VCgrO^^y^
6 Ho ly Cro b s Gem© tery Malden
, M. D
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
January 2.8, 19.6.I.
7 NAME OF
FUNERAL
ADDRESS
director Arthur J , 0 *Maley
Tfinthrop, Ma s a .
Received and filed
JAN U tea’
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
>0, ■ -a* McDermott
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
,Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry . ..£1© Q tr IC-&1 . COH tPAC t© T-
or Business:
15 Social Security No
16 BIRTHPLACE (City)
(State or country)
...Q2.3-.14-6.873..
Brooklyn
rTew York
17 NAME OF
father Michael Clarson
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Mary Ahern
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Ireland
21 Informant Hamlet M. C Ij&SOIl
(Address) Win tVurnp
j/aZ.
(Official Designation)
I HEREBY CERTIFY that a satisfactos^' standard certificate' of death
filed yrith md BEFORE the burial or transifpermit was issued:
,
{Signature oi Agent of Board oi Health or other)
0-928145
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF FRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
I R-301A
^RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
iot enter
than one
for each
(b) and (c)
oes not mean
e oj dying,
heart failure,
etc. It means
te, or compli- .
o kick caused
ou,
ons, if any,
;ave rise to
cause (a),
the under-
cause last.
dtions contrib- __
death but not
the terminal
mdition given
■ Chapter 137,
j|i954, requires
■ ns to print or
■e cause or
■>f death on
c tificates, and
:e 48, Acts of
tiiuires Physi-
t print or type
uler signature.
o
#5-59-925686
MEDICAL CERTIFICATE OF
DEATH
3 DATE OF T'mii'ir.r Oil
death January 2.U*
1961
(Month) (Day)
(Year)
X,
Suffolk
(County)
Winthrop
(City or Town)
®hr (Hommmtuipaltl) nf fUaaaarljuHPtta
if
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.
No.
60 Johnson Avenue
((If death occurred in a hospital or institution,
St. | give its NAME instead of street and number)
2 FULL NAME
Clarence A* Martin
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
f (Was deceased a
..j U. S. War Ve_teranp3L
(if so specify WART
(a) Residence. No. 60 Johnson Avenue, Winthrop
(Usual place of abode)
St.
Length of stay: In place of death.
24y
ears months
(If nonresident, give city or town and State)
days In place of residenc2.4. years months days.
4 1 HEREBY CERTIFY, That I attended deceased from
October 25, , 19 .6.0., to.....J.amary.....21i.,.., 19 6.1
I last saw KllB al ive on January 2k, w.6l-, death is said to
have occurred on the date stated above, at 10 *20.pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute .ny Qcardial inf arc tion
(b“e !°. Arte riosolero tic . .and .hyper-
tensive heart disease
£r..rXO.e.ne.ralized. . .arter±o.s.alarosis .
OTHER
significant none
CONDITIONS
INTERVAL
BETWEEN
8 SEX
9 COLOR
Male
White
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED ,
or DIVORCED WlClOWed.
10a If married, wid<
HUSBAND of
Alice Bixon
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
ONSET AND j| 11 IF STILLBORN, enter that fact here.
DEATH
3 mos
10
years
12
years-
Was autopsy performed? HO
What test confirmed diagnosis? ...Clinical., and. Lab .
5 Was disease or injury in any way related to occupation of .deceased? nO
If so, specify ..... A
/K , ~TX7"a v ^ n^t
..Trauns.teii,....Jr...,...IlJ..I).^
M. D.
(Signed) flh.
M. Traiias.tein.,....«j. ....... au.,..
(PRINT OR TYPE SIGNATURE)
(Address) 73 T* t~. ~l ft tt Rfj T1 j)ate ...J.an..25> ...is.6l
5 Winthrop Cemetery* Winthr op
Place of Burial or Cremation 7 . tCity orl
T angary 27th
DATE OF BURIAL
Town)
19..
.AGE..1
.00. .Years.. ...8 Months...2Q.
'.Days
If under 24 hours
Hours Minutes
Occupation : Boston. Harbor Pilot-Retired
(Kind of work done during most of working life)
or Business : Pilot.... Boats.
15 Social Security No.
'.CBL
16 B1RTHPL
(State or
-ACE (City) ... East Boston..
country) M,
as Si
7 NAME OF
FUNER
17 NAME OF
FATHER
Ambrose A. Martin
18 BIRTHPLACE OF
FATHER (City) ...rrnBOS.tODt ..dLC.ir........
(State or country) Mass.
19 MAIDEN NAME
OF MOTHER
Annie Beadle
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
.Boston.....'. ...i....u kD^...
Mass.
21
ADDRE
Received and filed
at. director^ ic hard C • Kirby , Inc.
91/1 Bennington St .Boston
. 2.6 Lies.] „
(Registrar)
Informant Miss Georgia Morgan
60 Johnson Avp .. Winthr op=
I HEREBY CERTIFY that a satisfactory Standard certificate of death
was filed with me BEFORE the-burial or transit permit was issued:
( Signature,©! Agent of Board of Health or other)
: O, A^..2.J...r/S.A£. )
(Official Designation) (Date of Issue of Permit) 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 of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians', see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
\ R-301A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
]iot enter
than one
s for each
(b) and (c)
'f oes not mean
['e o) dying,
heart failure,
etc. It means
re, or compli- ^
which caused
\ons, if any,
’gave rise to
II cause (a),
i the under-
i cause last.
itions contrib- .
death but not
> the terminal
ondition given
i- Chapter 137,
1954, requires
ans to print or
the cause or
of death on
ertificates, and
48, Acts of
equires Physi-
print or type
nder signature.
b-928145
X,
Suffolk
(County)
’Vlnthrop
(City or Town)
dnmmnnuifalt^ of iUaBaarljuarttH
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.
lJj
No.
2.1.0... Main Street
f (If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME
Mary Jane Culkeen (Sheer In)
(First Name) (Middle Name) (Last Name)
(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)
(a) Residence. No
(LTsual place of abode)
210 Main St. ,
..St.
Length of stay: In place of death years months days. In place of residence
.1.1 flirs
(If nonresident, give city or town and State)
months days.
MEDICAL CERTIFICATE OF DEATH
deIth January 25., 19.6.1
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, That I attended deceased from
OsjuJ. wil. ,0. j&l 'tnL i9 .£/...
I last saw h.
U
i luot ju rv n,,fr„„uii v v. on | 1
have occurred on the date stated above, at
... death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
✓A ONSET AND
JAU.T...K. ■ fjggj,
fbT To /n y o c J?/ & E*tr £
Due To
(c)
fhre&io^CLe^TicL rteyHz,
—jZrt V r Hf r • V' 7)rc. , sh
OTHER
SIGNIFICANT ^rr.
CONDITIONS £
Was autopsy performed? ...fy.f?.
What test confirmed diagnosis? ...
INTERVAL
BETWEEN
ONSET AND
zy/u-
If under 24 hours
Hours Minutes
yd)
5 Was disease or injury in any way related to occupation of deceased?,
If so, specify
( V A- T)
A'
(Signed)
* ( DD TVT AD TVIIT (
M. D
(Address)
•J VV
. fttmWYT SIGNATURE; /v ii
It* S/V rtlriu fl Dalc ■ / 19
6 Holy Cross Malden
Place of Buna) or Cremation (City or Town)
DATE OF BURIAL
January 27 196l
7 FUNERAL DIRECTOR . A rt hur J , 0 ' Mai ey
address .ftinthrop Mass
Received and filed . J 2 6 19"
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED . ,
or pMaanpiied
10a If married, widqjr^rLo, divorced __
husband of Fred Culke en
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
or Business: Sales lady Raymonds
...Q.i.i.r-24r.6846 :::
15 Social Security No.
16 BIRTHPLACE (City) .WlUthrQp
(State or country) l"»So
17 NAME OF _ , . , .
father Patrick Sheerln
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Ireland
19 MAIDEN NAME
of mother Susan Sheekey
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Ireland
1 Informant -- x
(Address) 2o Schoflpld pr, , Newton-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me> BEFORE the burial or transit permit was issued:
Of Board of Health or other)
/fZ
e of Hermit)
:
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 o(
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 decease! 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
iTRUCTIONS
FOR
4L CERTIFICATE
In giving
E OF DEATH
not enter
re than one
se for each
i> . (b) and (c)
does not mean
lode oj dying,
It heart failure,
L etc. It means
pare, or compli- ^
which caused
Ktions, if any,
p gave rise to
I cause (a),
the under-
I cause last.
editions contrib-
b death but not
I to the terminal
I condition given
II- Chapter 137,
| 1954, requires
Bans to print or
[he cause or
t of death on
fertificates, and
r 4g, Acts of
squires Physi-
p print or type
[ider signature.
lyi'i
1-11-59-926662
i.
2 Suffolk
(County)
rtf MaHaarljUHftla
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.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME..
Mary (Haggerston) Lougee (ff's' ‘
(If deceased is a married, widowed or divorced woman, give also maiden name.)
War Veteran,
[if so specify WAR)
(a) Residence. No .L5...8lp6n Stre§t St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence.. 91 ...years Qmonths. 28-days.
MEDICAL CERTIFICATE OF DEATH
3 date of January 2$x 19.6.1
DEATH
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
... January .7,..., if>2 to January 25^ ». 6l
I last saw h.r^lalive on J^PUa-Ty 29s, 19.6.1..., death is said to
have occurred on the date stated above, at „S..S.?.Q...]? ?...m.
8 SEX
I 9 COLOR
10 SINGLE (write the word)
MARRIED
Female
White
WIDOWED ,
or DIVORCEWldoW
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Arteriosclerotic aM. hyper tens i"v
heart disease
Rf ^Generalized arteriosclerosis
(b)
Due To
(c)
significant Hypertrophic. ...s.£th..F.i.tj,.si..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
o DEATH
8 yr
3 AGE . 91 Years .0. ...Months... 28. Days
10 yrs
12 yrs
Was autopsy performed? ...JrJ.Q
What test confirmed diagnosis? .CM.nical...&...lah9..ra.tQ3y..
5 Was disease or injury in any way related to occupation of deceased ? 110...
If so, specify^........,. 1
Vr-i- M » Trauno tein, Jr. , MJ .£■ .
(Signed) /id....* :/>.'..vr , m. d.
M. Traun.ste.in, .Jr..,.
..I.'.....”...".Wint.^
Place of Burial or Cremation
DATE OF BURIAL 19.
t (City or Town)
Jan. 28 10 6l
7 NAME OF
FUNERAL DIREC
ADDRESS ....
tojl Howard. G... Reynolds
W^throp. Mass
PERSONAL AND STATISTICAL PARTICULARS
Received and filed
JAN-SO-iSSl
(Registrar)
10a If married, widowed, or divorced
HUSBAND of
_ , , (Give maiden name of wife in full)
Edwin Lougee
(Husband’s name in full)
(or) WIFE of
11 IF STILLBORN, enter that fact here.
12
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Housewife
(Kind of work done during most of working life)
or Business: ... Qwn Home
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
None
V.'inthrop
Mass
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHFR ff'itv'l
Watertown
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Louisa Tewksbury
20 BIRTHPLACE OF
MHTHFR rritvA
Winthrop
(State or country)
Mass
‘informant ..Murray
(Address) 90 Terrace "Av e "" Win t hr "n p
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed^witb- me BEFORE the burtal oc transit permit' was issued:
* ^ of Board of Health or other)
fe.7/6/
(Dateyof
Mr. A.
(Official Designation)
: of Permit)
/■
/
SPACE FOR ADDITIONAL INFORMATION
- ' • t
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
- u'
T 0 \A/\
i L
RANK, RATING
ORGANIZATION AND OUTFIT.
/V-
A*
SERVICE NUMBER
2 AC,-
//}/
•••r;
rJA^ OlOl’IS.-GJx 1^
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service fqr 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.
)RM R-304
\j
(T
i In giving
IcAUSE OF
!TAL DEATH
do not enter
more than one
Jause for each
j| of (a), (b)
and (c)
al or maternal ,
dition causing '
il death (do
t use such
ns as stillbirth /
prematurity.)
a! and/or ma-,
\al conditions , I
ny, which gave I
e to above
se (a), stating
underlying!
se last.
editions of fetus
mother which
y have contrib-
e d to feta!
th. but. in so
as is known,
e not related
cause given
(a).
5M-6- 60-92824 1
P-
K
i Id
> Suffolk,
_ v Bounty)
V4
o Winthrop
fc (City or Town)
O
(Eontntottfaealtfj of jMassarhusctts
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
CERTIFICATE OF FETAL DEATH
(STILLBIRTH)
To be filed for burial permit with
Board of Health or its Agent.
Registered No.
21
fS no. Winthrop Community Hospital
NAME OF FETUS Baby ...Boy Foti
(if given)
St. j
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
3 DATE OF
DELIVERY
( Month )
26
(Day)
61'
(Year)
4 SEX ,/
5 COLOR (if
6 THIS BIRTH (Check one)
7 IF MULTIPLE BIRTH, BORN
Female ... Undetermined .
determined) VVi
Singld/'M Twin Triplet >
1st 2nd 3rd
FATHER
8
FULL
NAME
Ralph Foti
RESIDENCE, NO
CITY OR TOWN
164 Cotta!
East B.ofii
;e
ton
STREET
state Mass
10 COLOR OR Wh-i to I 11 AGE AT TIME OF id
RACE VVUX | Tins DELIVERY 0° (Years)
12 mRTH 0F Boston
(City or Town)
Mass
(State or country)
occupation Pressman
14
MOTHER
maiden name Antonetta Camiolo
present NAMi&ntonetta Foti
RESIDENCE, NO. 164 Cottage
city or TowNEast Boston
STREET
STATE Mass-
16 COLORtOi
RACE ,.WI
;ite
17 AGE AT TIME OF~ ,a
THIS DELIVERY JO..
(Years)
18 PLACE OF
BIRTH DO St OH
(City or Town)
Mass..
(State or country)
19
INFORMANT Moth er
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
(a) How many chiljlren a
now living? J
dead ?
(b) How many children werel (c) How many previous fetal
born alive ^it are nowj deaths of/_^NY gestation
u
21 LENGTH OF
22 WEIGHT OF/ FETUS
23 WHEN
DID
FETUS DIE?
24 AUTOPSY
Y
PREGNANCY
4 Lb. 4 Oz
Before
During Labor
Yes No
-A.
20 completed weeks
(or Grams)
Labor
X
or Delivery Unknown
25 FETAL DEATH WAS CAUSED BY: IMMEDIATE CAUSE
I HEREBY CERTIFY that this delivery occurred on the date stated
j-v . . n .above at 9*55 nAMnd product of conception was not a live birth.
(a) _ Premature scarring of placenta
Signature of Attending Physician or Medical Examiner:
Due To (b) Premature seperation and
Due To (c) bleeding causing insuff icien
to- ***** —
OT
CONDITIONS
26
Csfo S3
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
19 CeY
27 NAME OF
FUNERAL DIRECTO
ADDRESS
JAN 2 b 1961
Received and filed
A TRUE COPY ATTEST:
(Registrar)
M.D.
Address
NATL R E )
East Boston Dat l/26/96l"
I HEREBY CERTIFY that a satisfactory certificate of fetal death
was filed whh_jne BEFORE the buria,^ transit permit was. issued:
JljlMJL £
(Signature of Agen£"oTBoard of Health or other)
//- o • jh y (?/
(Official Designation)
S £ C L ! V £ 0
EXTRACTS OF CERTAIN SECTIONS
ACTS OF 1960.
/<C,Vil 12>vV
r> -- ,Xv.Uiu;//J Vx
0F'<yW»rf^*6 AS AMENDED OR ADDED BY CHAPTER 48,
Section 2 A. “Examination of JAN:>&l(i|$jf rfUurns of illegitimate births, or abnormal
sex births, or fetal deaths, . , . shall not be permitted except . .
Section 9 A. When a child is born dead, after a period of gestation of not less than
twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and
no movement of voluntary muscle, the physician or officer attending at the birth of such
child shall forthwith furnish for registration, at the request of an undertaker or other
authorized person or of any member of the family of the deceased, a certificate of fetal
death on a form which shall be prepared by the secretary of state as required by section
sixteen. Town clerks shall record certificates of fetal death in the town register of deaths
in the same manner as a death certificate, but they shall not be required to record such
certificates in the town register of births.
Section 12. “. . . No birth record of a child born out of wedlock or of a child of
abnormal sex, and no record of fetal death shall so be transmitted to any other city or
town.”
Section 2U- In any statement of births, deaths and fetal deaths printed by a town the
name of an illegitimate child or of its parents or of the parents of a child born dead shall
not be printed, but the word “illegitimate” or “fetal death” shall be used in place thereof.
A town violating this section shall forfeit to the mother of such child not more than one
hundred dollars.
..S.HEE.QLK
(County)
'i .WIN.THRQP.
(City or Town)
®l )t Commontoealtfj of jltlasgacl)U0ettg
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 fim/.r.'s*.
22
uri y. -? r\ a TTr^n 4- y* a {(If death occurred in a hospital or institution,
No. ...Xx. J.XXUXIXLU.JJ. £X^.^...w.X...£>..Q St. ( give its NAME instead of street and number)
2 full name HAB.Q.LD....E., FRENCH
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
((Was deceased a
( U, S. War Veteran,
(if so specify WAR)
M
(a) Residence. No 183 . Wint.hr op.. . St... st. ...Winthrop., Mass..
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months /....days. In place of residence T. years.. S. months... 7"* days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 death F. .January. 28* 1961...
(Month) (Day) (Year)
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.)
...Ror.anar.y .Q.c.clns.ion.;
..Acuta my.o.c.ard..ia.l infarction..
10 COLOR
U/A /it
11 SINGLE
(write the word)
MARRIED ct > « > ... ,
WIDOWED wo JJtZ • -
or DIVORCED fy
11a If married, widawed. or. div^tsfed /v , , ^ . .
HUSBAND of IT D&.M.pS.tSJ.
, (Give maiden name'of wifa/n
full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
5 Accident, suicide, or homicide (specify)
Date and hour of injury
13
Ai .
,.19..
Years....?. Months.. Days
If under 24 hours
Hours Minutes
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 ?
(Specify type of place)
Manner of
Injury
(How did injury occur?) * , r \
Nature of _ ■ ‘
Injury S .L.
While at work? Was autopsy performed? J^I.Q
14 UsuaJLj
Occupation :
Copiah /<t
(Kind of work done during most of working life)
15 Industry
or Business:
TqUsJ) of WlhAkkQA
16 Social Security No
17 BIRTHPLACE (City) th k.C 1/3
(State or Country) /Y f /
QQ£.~09. lr...7..T...!M...
6 Was disj
If so
fi.chaal....A. .
(Print or Type’
(Address) .B.Q.3..fc.Qnj MSI.S .5. 1......... Date ...JaiU g ,gi9 .6.1
18 NAME OF
FATHER
£ha French
19 BIRTHPLACE OF
FATHER (City)
(State or country)
/ W.J It
... n..o..wM
NVa,s. %
20 MAIDEN NAME
OF MOTHER
/Va kj u; y e Ir
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston.
/icxss
(State or country) /IcxSS
Informant .&■■■■
(Address) y f Us / » f F cfi J T Uj J M j fi t Via
ausfs
Wmi.kk.Qpj (SmM, Wjjj... i..A±.aA
Place of Burial, oryLrgmation y (City or Town^
DATE OF BURIAL . keb. ± /9t/
22
19
Ms. kk.lS..t..li/...../\ t-kAy.
ADDRESS 0/.O....ic/.m..tA.L^
8 NAME OF
FUNERAL DIRECTOR
Received and filed
JM-JO-latr w-
(Registrar)
I HEREBY CERTIFY that a sausfactory standard certificate of death
was filed yijth me J3EFORE the bindal or transit permit was issued:
Jty* £)iA...£.L ...s/...o.ff.>...^
(Signature yf A igen> of Board c# Health or other)
tf D 1...
(Official ^Designation) ^/'fj/ate of Issue of PermyO
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 Jpj" jtlj^ ^feeEfajifj* 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 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 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 fracture 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.)”
1M R-301A
STRUCTIONS
FOR
AL CERTIFICATE
n giving
E OF DEATH
not enter
re than one
se for each
), (b) and (c)
does not mean
ode oj dying,
heart failure,
etc. It means
sase, or compli-
which caused
ilions, if any,
t gave rise to
cause (a),
g the under-
cause last.
Inditions contrib- ^
r" i death but not
to the terminal
I condition given
- Chapter 137,
1954, requires
ans to print or
he cause or
of death on
srtificates, and
48, Acts of
quires Physi-
) print or type
Tder ignature.
r\' ^
!< -11-59-926662
L
Suffolk
(County)
Winthrop
(City or Town)
ulfjF (Emtttttmuuealtff of HHafiaarliusrttH
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
|fl DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
33
No.
Winthrop Community Hospital
Mary C ( Hurley) Sullivan
( (If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
((Was deceased a
2 FULL NAME * ~ ' 1 . -lU. S. War Veteran.
(If deceased is a married, widowed or divorced woman, give also maiden name.) lif so specify WAR)
(a) Residence No ^0 BateS St
(Usual place of abode) - (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)
(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
$jSkC-.l. nUL, to / / 2L ^ vd/
I last saw h^?L_alive on . , \%r. /....., death is said to
have occurred on the date stated above, at (m,u.J..C?rS....m. INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) d.tfAz .P..4'.B.O..M.AAfr./A
'b)e Ti. ' A /? t&ri - $ c /l£ ftc T‘ c
Sf-ziA P'r V /S £
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? . ~IZ£Z
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
M. D
If so, specify
(Signed) .
S^7Y>£d 7?£Mrl/fr /7A//iO
^PRINT (JR TYPE SIGNATURE) ,
(Address) U l PefL £&$ A^ JST... ... Dat g..../.d... v).v./r...
J71 Winthrop "
(City or Town)
..February 1 1961
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
or’Vii^^ibwed
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
— - (Give jnaiden name of wife in fi
Ed wa ra F . Su 11 i van
(Husband’s name in full)
full)
11 IF STILLBORN, enter that fact here.
T2 88
AGE Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
..Housewife .., ...........
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Dorchester
Miss
17 NAME OF
FATHER
John Hurley
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Frederick ton
New Brunswick
19 MAIDEN NAME
of mother Mary McGrath
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
..Frederick ton
New Brunawl ck-
Place of Burial or Cremation
DATE OF BURIAL
He la n A , Sullivan.
SO Bates Ave. , Wlnt.hrAf^
7 FUNERAL DIRECTOR .. Arthur J. Q ’Malay
Winthrop Maas
ADDRESS
Received and filed 19.
egistrar)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING 5..
ORGANIZATION AND OUTFIT
SERVICE NUMBER
•. XL
•:0#“ %'cW-
*.*•■
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 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 deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
I R-301 A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
:ot enter
than one
for each
(b) and (c)
oes not mean
e oj dying,
heart failure,
etc. It meant
e, or compli- p
which caused
■ms, if any,
•ave rise to
cause (a),
the under-
cause last.
Uions contrib- ^
death but not *
the terminal
mdition given
Chapter 137,
954, requires
Its to print or
: cause or
if death on
ijtificates, and
48, Acts of
| uires Physi-
Iprint or type
ller signature.
I li-59-92 5686
4
(Hmmttnnuipaltlj of UtaaHartyuHPtts
3 Suffolk £ x
“ (County) V^-' /
U. >
O N*
L .Win.thr.QD.
lu (City or Tv
own)
no. ..lijatiir.o.p C.onv.6
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.
24
((If death occurred in a hospital or institution,
H fflllP. St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full NAME -Hfirmine J.« Crane ( Mugler.....) warve^an,
(If deceased is a married, widowed or divorced woman, give also maiden name.) [if so specify WAR)
(a) Residence. No. 24 Spring. S.t.*Mans.£.i.eldrMass.# st. ...Wi-nthrop.. Mass-.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years l.months...ll.days. In place of residence 5 years 5montlls- ■■••8 days.
MEDICAL CERTIFICATE OF DEATH
death ...January 3..Q. 1.9.61..
(Month) (Day) (Year)
4 1 HEREBY CERTI F_Y That I attended deceased from
i9..6.<3^ \o...*J/9.#.a.4k&Y...*f.a. 19^./
I last saw htOT....alive on ..
have occurred on the date stated above, at .m.
.., 19.. it./...., death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
/oy>e
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? . 43L
What test confirmed diagnosis? -
5 Was disease or injury in any way related to occupation of deceased?
6 .....Wint.nr.Q.p C.eme.tdry. .....Winthr.o.p..* Mai
Place of Burial or Cremation (City or Town)
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
married Widowed
WIDOWED 'J.UUWCU.
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of .
(Give maiden name of wife in full)
(or) wife of ....Charles. A.. Crane
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE...6..6... Years 4-Months 2... Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : h.O..US..e.Wlf fi.
(Kind of work done during most of working life)
or Business own horns..
15 Social Security No „.,n,Qn.S
16 BIRTHPLACE (City) i4eri.(ikn
(State or country) Gorin fiT.l (Tit
17 NAME OF TT >
father Herman Mugrer
18 BIRTHPLACE OF
FATHER (City)
(State or country) T*TT1 ATI y
19 MAIDEN NAME
OF MOTHER Hpnninp Mommendey.
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Germany-
£•
informantHermiue. G.* aLxeira
(Address) ?£ Snriny St.. Mansfield
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with roe BEFORE the JrariaL or transit permit was issued:
Maas.*
2C ilA.JJl.AL
Designation) (Date of Issue of Permit)
1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF JS&T2I96I f"
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«i 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.
RM R-301A
NSTRUCTIONS
FOR
CAL CERTIFICATE
In giving
SE OF DEATH
lo no* enter
iore than one
mie For each
a), (b) and (c)
i does not mean
mode of dying,
as heart failure,
i ia, etc. It means
isease, or compti-
s which caused
6
ditions. if any,
ch gave rise to
ve cause (a I,
Ung the under-
g cause last.
onditions contrib-
to death but not "
F to the terminal
; condition given
f Chapter 137,
f 1954, requires
:ians to print or
the cause or
I of death on
certificates, and
rr 43, Acts of
requires Physi-
to print or type
rnder signature.
!B 20 1961
! 4-11-59-926*62
a ^ M PI
fCojfnty) I-
/3r/q47^o>i
(Cffy or Town)
OUT - Or -
ultjp (Enmmnnuiraltlj of illaflBarljUBFttfl
25
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
Registered No.
No.
S.A.. J/oSy&r
St
{ (If death occurred in a hospital or institution,
. ( give its NAME instead of street and number)
ffwoi
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorceflwoman, give also maiden name.)
f(Was deceased a
2 FULL NAME /. 4r. rr...:. ! > ,r7. \V. S. War Veteran,
[if so specify WAR)
ItiLzL
(a) Residence. No.
(Usual place
. /68 s* W/* t o
of abode) ^ dr-S . (If nonresident, give city or t
town and State)
Length of stay: In place of death years months..
In place of residence. JL.C/years months days.
MEDICAL CERTIFICATE OF DEATH
3 DEATH*1!..... Cfe* // /96/
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY, That 1 attended deceased from
19...44 to L~. S/. 19..^/
I last saw hf.ffli.. alive on /...- /./.. ., 19. &L , death is said to
have occurred on the date stated above, at m.
8 SEX
9 COLOR
" HAHK.EI. SiflffTS"’
Male
White
WIDOWED
or DIVORCED
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) c4***>ts yi.kM.rL.
Due To T
(b) C...
m.fR.«s^9ety..h A.3 e
Due To
(c)
/*? y neirfail .v\f!V«rjctt r c t ^ V
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? ... y.QrS..
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? *l.4R
if so, specify _ _
(Signed)
«^ron:....K...:.....«r r..u,...mrx^rm« M. I).
,7..f>A.tn. /?•. sLam!rfl!S..*...Cl*..X>...
(PRINT OR TYPE SIGNATURE)
(Address) Y^...O ^l/lT»..: Date 19. 6/
6 Holy Cross Cemetery Malden
Place of Burial or Crem^jo- (City or Town)
DATE OF BURIAL ,V SHUaPy ,,14* 19 .61
7 NAME OF
Arthur J. O’Maley
^^^m^antTc 3t. TIr throb
Reco Ki) atrf? filed -yiX
m— t — • it* a.
:U.'
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
II IF STILLBORN, enter that fact here.
12
AGE
-,e....6.7
Years Months..
..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
or Business: ...Finance U . fray e„nnm.e..n.t
15 Social Security No
16 BIRTHPLACE (City) ... B.Q.S..t..Q.Il
(State or country) Ma gSaOmlSet.t. fl
17 NAME OF
FATHER
John E. Lynch
18 BIRTHPLACE OF
FATHER (City) B.P„S..t..QXl„,
(State or country) Ma 8 Sa ChU S 6 t t S
19 MAIDEN NAME
of mother Mary A. Flynn
20 BIRTHPLACE OF
MOTHER (City) *.r.®.l.&nd.
(State or country)
Informant Iphn Sj, LVJlC.h., J^.a, ,■
(Address)//,
I HEREfiV CERTIFY that a satisfactory standard certificate of 'death
was filetl vJth me BEFORE the buml or pansit permit was issued:
\jf
(Signatured Agent of Boani of Health or other) jr/
3 3 ST *1^'
(Official designation) (Date of Isaue of Permit)
A TRUE COPY ATTEST:
OFF /.
FEB 201961 f'n
I R-301A
RUCTIONS
FOR
C E NT I f 1C ATI
Riving
OF DEATH
lot enter
than one
(or etch
(b) ind (c)
oe i not mean
'e ol dying,
heart failure,
etc. It meant
... or rompll- ,
which caused
[>
ont, I) any,
gave rise to
cause (a),
the under-
cause last.
illont conlrib-
death but not '
the terminal
audition given
Chapter 137,
9JS, rroulrea
is to print or
; ciuse or
f death on
tificstes. and
48, Acts of
nlrrs Phyal-
nrint or type
to
SUFFOLK
BOSTON
(5^p <2Inmmomitpaltl| of H3a00arl)U0ptt0 -
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
(City or Town)
MASSACHUSETTS GENERAL HOSPITAL
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Apent.
Hefiri^tered No.
oorvro
No,
St.
1(11 death occurred in a hospital or institution,
I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
_ _ _ ((Was deceased a a r
1 FULL NAME .ThCmaS . .Ra....0,.ConnOr U. S. War Veteran, «one
(II deceased is a married, widowed or divorced woman, give also maiden name.) I if ao specify \\ AR)
(a) ReMdence. No. l8U Saner set Avenue st. Winthropy Massachusetts..
'Usual place nf abode) _ _ flf nonresident, give city or town and Sti
Length of stay: In place ol death..
years months ??.... .days. In place of residence “7 years months days.
State)
MEDICAL CERTIFICATE OF DEATH
,ignH96
b
l Dirac tori
tun only
\.K Ink.
A-c •
i* 39-923684
3 death1! January 16
(Day)
(M onth)
1961
(Year)
TI HtREtlV CE.RTIFY, That FOntpnded deceased Jroti
January 15 rOI , t0 January Ip i-bl .
W«4ast saw hilBallve on January l6 19. 6l, death is said I
have occurred on the date stated above, at 4 :00 p
DEATH WA8 CAUSED BY i IMMEDIATE CAUSE
8 SEX
9 COLOR
I0S1NOLE »>uilfciha wood)
MARRiEnMaxT led
Male
White
WIDOWED ii.v,
mi DIVORCED ‘ 1
(•)
JsJLLkQl
(^el!...foo.Pl<.M6A.U VaFKCS
$eTo ..A*..6n.N6C'.S. C iMHojis
OTHER
SIC.NIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET ANO
DEATH
'hrutL
P-
rJ
Was autopsy iierformed ? l
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) - M. I).
Chorl.a L. Cloy, M.D. f
(PM NT OR TY PE ' SIGN ATURE)
(Address) Date-Jon.. l6 19. 6l
« Winthrop .: w in t nr op Mae b
Place of Burial or Cremation (City or Town) .
DATE OF BURIAT 19, .©I
I’l R80NA1 AND 8TATI'<Tlt At PARTICULAR*
10a If married, 'P'-fBAUDie 1 8 teT
HUSBAND of v „
((live ittaiilrtt namr of wife In full)
(or) WIFE ol
(Husband's name in full)
II IF STILLBORN, enter that fact here
A(!F. 5^ Years 3 Months ^
If under 24 hours
Hours
Minutes
13 Usual
Occupation :
Machine Operetor
14
industry Marine Hardware
-ii-in A
15 S4vrinl Security No. ^
i< hid™ ni ire BO0tOn., _
(State or country)
FIB BB
17 NAME OF
father Thomas
0, Connor
(✓)
1R BIRTHPLACE OF
patwpr rritv^
Boston
H
Z
(State or country)
Maes
19 MAIDEN NAME
OF MOTHER
Roeella Doherty-
30 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Boston
Hass
7 NAME OF
FUNERAL
ADDRESS
Wlimlilizlfr"0
JAJU.il 1361.
a./...... 7-v.
Informant
(Address)
Jane Q* Connor
Bdmeree
I HEREBY CERTIFY that a satisfactory standard certificate of death
waa ftM with me BEFORE tht burial or transit permit was issued:
Uct C - «Jt ^ cU (L
~tr
(6ftciai Designation)
(Signature of Agent of Board of Health or other)
/) ^ V.*L.Sr. L-J.Lz..kL
. i a ‘ /11.4 a a! I ■ a*«a o I Uae in I • )
(Data of lasua ol Permit)
MAR- 6 1961 AR
M R-301 A
ITDUCTION*
FOR
U CERTIFICATE
n Riving
£ OF DEATH
not enter
e thin one
se for eich
, (b) end (c)
i Hon not mean
nte ol Hytnf,
\ heart failure,
i|, et( It means
I air. or tompli-,
i which mused
■(
\ V*
lions, II any,
lave rise to
rouse, (a),
the under -
cause last.
dlllons ctmtrlb-
Heath but not "
| to the terminal
ondition flven
li- Chipter 137,
I 1954, require*
ins to print or
he cause or
f of death on
Irtificite*, and
4S, Act* of
quire* Phytl-
print or type
ufer signature.
YW
\R 6 1961
R-6-30 92S6S6
QJIjr (Cnirnmiiunraltlj nf
JOSEPH D WARD
P Bob ton
AfCRFTARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
J FULL NAME
,,5T.
An to
V /II .1--
HWPiTR*-
Suffolk ,
(Conn tv)
(Ci tv or I own)
tonetta FamigfUi.-—,
nTot^erffc FAvn <s yen; ,
(If deceased is a married, widowed or divorced woman, Rive alsiymaiden name.)
Ti testa H (?oAO
, / C.y* In ,.l»r» ,,f 1"
To hr filed for burial permit
with Hoard of Health
& i
Registered No,
or its Agent,
onr»79
. f (If Heath occurreH in a hospital or institution,
St. | give Its NAME Instead of street and number)
PHYSICIAN — IMPORTANT
(Wat deceased a
U. S. War Veteran,
j if m specify WAR)
la) Residence. N
1 1 Nual place ol abode)
wtnwfibp
(If nonresident, give city nr town and Stale)
I engib of Slav In place o( death
month*
years
months
day
MEDICAL CERTIFICATE OF DEATH
iZSEBSBBZEZJBL
(Day) |
J DA T
PEAT
(Month)
Jl J? If E II Y l E It I i I Y
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
(Year)
attended dei eased b"T
E It I I E Y , I bat I ail i
W 19,4 to CT lO \t6/
I In ^t *aw hdlivjon -TAN 20 ...... , |Q > death in *aid tn
have occurred on the date stated above, at 6,'«rA rm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
, Co tic esn ifi Hfiwtr
Due To
(b)
CAAQlAL inPflgCToW
Due T,
(C)
Heflin Oiie-wf
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed f
What test confirmed diagnosis?
INTERVAL
BETWEEN
HIT AND
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed
-Xr
M D.
v . rrt r 6 r F. ' r?> / w ~ ” t
(Address) £X Date ./ J 2*1 1 .19 a
6 B t Z1M1 cha el T 6 ~~ 13© e ton Ma§f~
Place of Burial or Cremation
DATE OF BURIAL
Jan 23
(City or Town)
7 NAME OF
FUNERAL
ADDRESS
'W*lnth?op ItCS?|i|g2p
(Registrar)
9 COLOR
III SINlll.E
MARRIED
WIDOWED
or DIVORCED
H SEX
female white
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wile in lull)
Baffaele Famlgllettl.
(Husband's name In full)
married
(or) WIFE of
II IF STILLBORN, aniar lhai fart bara
12 71
AGE '.. Years
If under 24 hours
Month* Pay*
U Usual
Housewife
(Kind ol work done during most of working life)
14 Industry
At Home
v' 1 f.
15 Social Security No.
,.U..\...N..%^.
1* BIRTHPLACE (City)
(Slate or country)
Italy
17 katherf Antonia Balerno
18 HIRTHrLACE OF
FATHER (City) ...
(State or country)
Ttaiy
19 MAIDEN NAME
OF MOTHER Marie Conti
30 BIRTHPLACE OF
MOTHER (City)
(State or country)
( a* d Tress) ycoSrlpfei; wintSroo^Maeg
tF.BY CERTIFY tha* a -saljsfiJlory sfhndard certificate of death
with mejjlf F.OJLtJ thej| bpyia(| or t ran srV^ perm jt was Issued:
\gent ol Jipard of Healtlj or c^hfr)
R £C S V EC
- /; t : 1 3 2
Oi i V^/ .-'■ i"'
A&\. ,^£4J * '
’■-^SLS
MAR -61961 AH
fS cutffcU’
>RM R-301 A
INSTRUCTIONS
FOR
CAL CERTIFICATE
In Riving
SE OF DEATH
do not enter
lore then one
■use (or each
a), (b) and (e)
Ij does not mtan
mode o / dying,
as heart failure,
i ia, etc. It ifeans
lie ate. or compll- ,
hich paused
\
7
lions, if any, j
\fh gave rise to I
cause (at,
li'nf the under ■ I
| jr muse lust. J
onditions contrib-
to death but not '
to the terminal
condition given
Chapter 137,
( 1954, requires
I isns to print or
the cause or
of death on
ertificaies, and
r 48, Acts of
Requires l’hysl-
t o print or type
ndrr * I m n a t lit e .
|e\r 6 1961
1-11-59-926662
* SvpjA .
Qlnmnurmuraltlf nf fflaflflarfjtiflrttii
JOSEPH D. WARD
alCRETARV OF THI COMMONWEALTH
DIVISION OF VITAL STATISTICS
Imm /B
(City'n^l \A/n) t v
no Jkfa/nJ €sii/ihe7kfr /A&iiJ*/
STANDARD
CERTIFICATE OF DEATH
OF-TOv • 2H
To In filed fur hurt n I permit
with Hoard of Health
or its Agent,
Registered fjtl
2 FULL NAME,,
$9 It* oou fo / baJL
(If deceased is married, wiil^wrd nr uivorceiyvoman, give
(a) Residence. No
(Usual place of abode)
/SO
also maiden name.)
I(I( death occurred in a hospital or institution,
St. J give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
[(Was deceased a /
<U. S, War Veteran, / /_
tame.) * |if so specify WAR)
s« U///)i&?opj ///9SS
(If nonresidentjf^re < city or town and State)
Length of stay: In place of death yeara months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OE
DEATH
‘3lu/ JL
(Month)
(Day)
(Year)
* -I i Ji E n Y CERTIFY, Thai I attended deceased from
TAMJl 6A, CT7TM' 2JL ni/
I last saw h/iBalive on J StM M/ 19 death ia aaid to
have occurred on the date stated above, at m. INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY i IMMEDIATE CAUSE
ic/n
(a)
fitc/ecMsis
Due To
(b)
Due To
(0
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
?70
DEATH
ihL
S Was disease or injury in any way related to occupation of deceased?
If so, specify
K&
(Signed) zcwweu. .... m. d.
O.esww i it. v j t lntj..iK.es. *
. LRRINT.OK WI’E SIGNATURE) j
(Address) oSr*Jc7/J^ fl v£*i**& //OSfi. Ysu\t. ....... JAM... „.I9^/
. *^s±JmE3Sefm
Place ol Rttrial nr Crem«ioa^x’;> ^ [A[<S ^ ”r°Wn^ (j[/
DATE OF BURIAL
7 NAME OF
FUNERAL DIJUECTO
ADDRESS /r
ADDR
(Registrar)
8 SEX
WaA
PERSONAL AND STATISTICAL PARTICULARS y
(IKK ^“Twrite
0 COLOR
lA/t
in siNt
MARRIED
WIDOWED
or DIVORCEDfll^
the word)
10a 11 married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IK STILLBORN, enter that fact here.
12
AGE Yeara Months Days
II under 24 hours
Hours.. ..TIT. Minutes
13 Usual
Occupation :
(Kind ol work dune during most ol working lile)
14 Industry
or Business:
15 Social Security No.
lft BIRTHPLACE (City)
(State or country)
....
18 BIRTHPLACE OK
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
u/aAA
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
/nec/AiA /mSJr
til vwu ■ i i i y j j
m. M.
Informant
(Address)
I HEREBY CERTJFY that a satisfactory standard certificate of death
was flit
kD-wkh-mc BEFORE the burial or transit permit was issued:
[' )d: ...J^eA^.. ?. 7>-
,/ (signatuia of AAfnt of Board of Health «r other)
Slgnatuta i
L3A WJAL ,,
(Official Designation) (Date of ls»oe ol Permit)
A I RUE COPY ATTEST:
. z-n c^eEt.
City Registrar
- — •' — ' ■- C1
LL- i
•J)
Q%. #4/
/V
M-6I3E! Bi
RM R-301A
B.-THIS IS A
IANENT RECORD.
Ui« only
TE APPROVED
ck ink or black
•writer ribbon.
ItTRUCTIOHI
PM
Ml CERTIFICATE
In giving
E OF DEATH
a not ontor
re than one
tit (or oaeh
), (») and (c)
I dart tar mta t
10 Jr 0/ d\ in/,
[I heart failure,
I, etc. It meant
rate, or rom pH- '
which earned
!W
riot;, 1/ tty,
tave the
tanu (a
the under-
eaute tail.
tdiliont eantrib-
> death but not
la the terminal
canditian liven
■ Chapter U7,
1950, require*
em to print or
he eauie or
of death on
rtlflcatea.
4AP. 46, II 9 &
IAP. 114 SS45,
iHApmi
il Director!
vi® wily
iCK Ink.
JikC.
Iio-seenese
‘.M
in
3 — *
IS
1 \o BOSTON
(City or Town)
SUFFOLK
(County)
A(Ehf (Eommomuraltli of USaHHarhuBrltfl . unv->
<& EDWARD J. CRONIN
wF 1
) 7
EDWARD J. CRONIN
• KCNKTAnY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTIC®
STANDARD
CERTIFICATE OF DEATH
To be Died for burial permit
with Board of Health
or ita
Registered No.
YIT070
Maseaehusetts Centrol Hoepltol BAKER MEMORIAL /(If death occurred in a hospital or institution,
- St.\a
2 FULL NAME-. -
(If deceased la a married
No Jj&'dfi - St.\give ita NAME Instead of street and number)
VI mi NX A uFLIS TEN [ Godfrey).. — .....
, winowea or divoro^T women, give alto maiden name.)
175 Bartlf tt Nd,
Length of stay: In place of death years 1... months 5 days. In place of residence AAy
(a) Residence. No
(Usual place of abode)
I PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if ao specify WAR) ........
st. ... W I n thr op , .Maas ....
(If nonresident, give city or town and Stale)
a 5- months 2.7 day..
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Mont
£(,nu,pY ,??,» 1961
(Year)
< I HEREBY CEITIFY. That 4«ttended deceased from
December 239 6Q. to January 28, i?6l
v*laet saw h« ytlive orj « nU*rj 28 . • ”61
have occurred on the date atated above, at H* 0>H
A SEX
9 COLOR
10 SINGLE (write the word)
f omale
white
MARRIED Vit - J
widowed married
or DIVORCED
death la said to
DEATH WAS CAUSED BY I IMMEDIATE CAUSE
(a) G A ZtK O
// R. R-k e
(b1)'1.0 A u&fk .Mu e / o
L^ u K cs>\ m-
Due To
(c) —
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
IETWEEN
ONSET AND
DEATIj^.
(o M
t s
Was a^itqpsy performed? Yt9 -.
What test confirmed diagnoale?.. A lltj OPS ft---
5 Was disease or injury in any way related to occupation of deceased
If so, specify ....
(Signed)-..
(Addreaal.-AntS^eXVhV^SwAfens
M. D
Datel-28-_ l6l
Place
Winthrop Cemetery ..Winthrop, Mas
ace of Burial or Cremation (City or Town)
DATE OF BURIAI^.-%n]i8^
7 NAME OF
FUNERAL DIRECTOR
address 17.4. .Win
Recti v#4' Ind (Red ...
ir„op._.§t_,
■ec “
Winthrop,
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife In full)
(or) wife of Roy Milton. Rliater.
(Husband's name In lull)
II IF STILLBORN, enter that fact here.
12
AGE44 Years ..5—Months 27- Days
If under 24 hours
Hours Minutes
U Occupation: hQUSewlfe
(Kind of work done during most of working Ufa)
14 ^Business: qw n home_
15 Social Security No.—
.011-01- 22b 6
16 BIRTHPLACE (City).
(State or country)
Jin.thr.pji ,
laaaachuae
17 NAME OF
FATHER
George .Jason Godfrey
1A BIRTHPLACE OF
FATHER (City) ..N.Qr..tllWQP.(Ji-fi.tX4_
(State or country) New Hampshire
19 MAIDEN NAME
OF MOTHER
Winnifred Ladd
20 BIRTHPLACE OF
MOTHER (City)-... Mercer.
(State or country) _Maine_
Informant ROy M*.
(Address) iys Bnr
ter...
etf Road.WintKrQD-
>«»jyAjJled with/nfe BEFORE the burial oi
h.±cL
(Signature of Agent of Boafd of HeaHh or other)
9S
(Official Designation)
(Date of Iaaue of Permit)
I HEREBY CERTIFY that a satisfactory standard certificate of death
' ‘or transit permit was issued:
US 0£: V E D
R-301A
UCTIONS
OR
CERTIFICATE
living
)F DEATH
tt enter
;han one
for each
b) and (c)
not mean
oj dying,
eart failure,
tc. It means
, or compli-
hich caused
is, if any,
iv e rise to
ause (a),
'he under-
ause last.
ions contrib- -
eath but not
the terminal
idition given
phapter 137,
54, requires
s to print or
cause or
death on
ificates, and
18, Acts of
tires Physi-
rint or type
:r signature.
& '
-59-925686
IX
b Suffolk.
(County)
1
ulfjr (Enmmnmuealtlj nf HaafiarljuHPttH
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.
so
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
L Winthrap
iU (City or Town)
<
\sJ no 131 Terrace. Avenue..
PHYSICIAN — IMPORTANT
2 FULL NAME J.amSS C..Qnra.d....Hel.S.O.n . IjtL Is ^Veteran, wn
(If deceased is a married, widowed or divorced woman, give also maiden name.) (if so specify WAR) IM.U.*..
(a) Residence. No 1.2 .River.....RQ.a.d st ,.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months.. 1.4 ..days. In place of residence. ...34.years months days.
MEDICAL CERTIFICATE OF DEATH
DEATH February 5 19.6.1.
(Month) (Day) (Year)
41 HEREBY C ELT I F Y , That I attended deceased from
J)e.cem*>$r. t0 w
I last saw h/J*lalive on ... /£. , 19.4/... ., death is said to
have occurred on the date stated above, at fy ./xn.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
/ s
(a)
Due
(b)
T;'C*rciho)r\\ ojf €^4^**
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
£>nruo
ijrs
Was autopsy performed? SMi
What test confirmed diagnosis? mm.QY.U-.-
5 Was disease or injury in an^ way related to occupation of deceased ?
If so, specif
1
m :
p . ..C-. u-y'vx \y
.Li'RKiT OR TYPE SIGNATURE)' y? /) / .
(Address) f/j'i.pl. £ A Date../h.^£24r?. 19 Lo I
6 Winthrop G.e..d.e.te..ry. )Vintiarpp,...4
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ”
7 NAME OF
FUNERAL DIRECTO
address 1.7.4 .WX£E Lc.o..p...,.S..tu> Wln.thr.Q.p.r.
Received and filed
F££f §■ tbbl
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE (writ^ the word)
MARRIED Wl<
WIDOWED
or DIVORCED
10a If married, wido
HUSBAND of .
(or) WIFE of
011.vi.er. J.akabsen
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE..6.9....Years.... 10.
Months.
,.2.Q.Days
If under 24 hours
Hours Minutes
13 Occupation: S-fi-lf fiJHpl.Qy.e.d
(Kind of work done during most of working life)
or Business: paint and pape.r......hange.r..
15 Social
Security No. .Q.3..Q.-.1.Q.-..7.9.441
16 BIRTHPLACE (City) .„..T.Q.nS.b$..I’g
(State or country) I' O PWRV
orwa-1
17 NAME OF
father Yohan Nil laser) Bjune
18 BIRTHPLACE OF
FATHER (City) ....
(State or country)
.Ranm.es
Norway
19 MAIDEN NAME
OF MOTHER
Karen Yoneyang
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Ramnes
Norway
informant Ml®* M* Qg-lS
(Address) 131 T erraop Avg , VJ-] nthr^p
1/lass-,
^TIFY that a satisfactory standard certificate of death
? BEFORE the burial or /(ransit permit was issued:
. . .Lod/L. ... ■■ . d ■ . . . .f . . . , -- ^....^-. 2.. — C — f'~
'(Fignatute'ofCAgent of Boar<L*PRealth or other) /
WU/-. *>_ /ILL
Designation) (Date of Issue of "Permit) f
SPACE FOR ADDITIONAL INFORMATION
•if .V. .
DATE OF ENTERING MILITARY SERVICE...,^^.,
DATE OF DISCHARGE
\^n\
u (Cs-i sf4MAy = aa
*v§*W?7c,-.
RANK, RATING
rrO!jT
ORGANIZATION AND OUTFIT
SERVICE NUMBER
• • -6-
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
R-301A
UCTIONS
OR
CERTIFICATE
giving
)F DEATH
i»t enter
Ithan one
for each
| b) and (c)
Ej not mean
I of dying,
seart failure,
j/c. It means
l, or compli-
Mich caused
>i, if any,
‘rue rise to
.ause (a),
If Ac under-
cut e last.
fions contrib- .
ath but not
the terminal
ition given
ll'hapter 137,
K4, requires
Is to print or
I cause or
I death on
llificates, and
■•8. Acts of
lllires Physi-
Irint or type
It signature.
159-925686
(County)
...Winthro.«;
(City or Town)
(Emmmnuuraltfj nf fHaafiarhuarttfi
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.
‘M
Registered No
o
No.
St.
I (If death occurred in a hospital or institution,
I give its NAME instead of street and number)
me
PHYSICIAN — IMPORTANT
2 FULL NAME Mill.i.am....Er,anklin....Ke.lt.h-, lu' If V\Tr Veteran, No
(If deceased is a married, widowed or divorced woman, give also maiden name.) I if so specify WAR)
a) Residence. No 11.0. OTOSSJCS. MfillUfl St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years. ..4- months days. In place of residence years. months days.
MEDICAL CERTIFICATE OF DEATH
DEATH 'F ZeJb 6 .jy II.6I
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, That ,1 attended deceased from
...Q..c..t., y. 19JD.Q, to Zeb... 6. ».aL
I last saw h.XLllive on ... ESJLn .6. 19....... death is said to
have occurred on the date stated above, at .3. I INTERVAL
BETWEEN
ONSET AND
DEATH
-l-?5
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
care adL-df
(a)
(b)eTp.-C ' e sclerotic he ■ rtclise
Due To
(c)
OTHER . ,
SIGNIFICANT ....jD.©..C..l.lb.i..ti.lJLS. P..t llC.S.l..
CONDITIONS
8 SEX
9 COLOR
Male
White
6 1
se
2 mo
W- a s autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify X1Q...
(Signed)
.-A. a y.L.A.tb.S-.fJ.Jl..
(.PRINT OR TYPE SIGNATURE)
(Address) r.r..in.c.a.t.an * i£te 2.-..Z
6 } E Q Cr . I "j 3 to n
Place of Burial or Cremation (City or Town) f
DATE OF BURIAL .L®.brUary 19.0,1
7 name of i'he i ie± l W]
FUNERAL DIRECTOR
address !T. s t Bro line.
^ n s . 7
ZTEffZf
Received and filed
Lnc
la
.19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED ;
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of j..l.Qr.G.L..C.e Li iL..
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here
12
AGE
,9.1..
Y ears...!.
..Months
J
Days
If under 24 hours
Hours Minutes
13 occupation : L.l.au.QX,,..H]iQ.l.s.s,al.c..s,
(Kind of work done during most of working life)
14 Industry , . ,
or Business:
15 Social Security No flG-Fl©"
16 BIRTHPLACE (City) ....Lr.Q.
(State or country) 1;
17 NAME OF . .
father Phmei tn
18 BIRTHPLACE OF
FATHER (City)
(State or country) TIei.r Tb TIT) flh ~i Tfl
19 MAIDEN NAME
OF MOTHER
.
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
-onn,
‘informant UX..?..., CL iil.dr.i..C.h.
(Address) T -r - ■ -* '■ - ' ~ - -. ~L4.
J •'•44-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed wjth'TSe BEFQRR' the burial or transit permit was issued:
£
(Signatur/ of AffleatoT Board of Health or other) /
r *** ¥ia- , y//:,
(Official- Designation) (Date of Issue of Pe/mitj / J ^
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
H R-301A
RUCTIONS
FOR
L CERTIFICATE
i giving
OF DEATH
not enter
t than one
|e for each
(b) and (c)
moes not mean
ffle of dying,
heart failure,
etc. It means
ise, or compli- p
1 which caused
ions, if any,
gave rise to
cause (a),
the under -
cause last.
litions contrib- .
death but not ^
\ the. terminal
ondition given
Chapter 137,
1954. requires
ns to print or
e cause or
pf death on
rtificates, and
48, Acts of
quires Physi-
| print or type
der signature.
11-59-926662
(I ZjAlA
Qtyr (Emnmmuuraltlj of iUaasar^UHPttH
(County)
JOSEPH D. WARD
r SECRETARY OF THE COMMONWEALTH
li* DIVISION OF VITAL STATISTICS
jo W/ n h h 6
fo a^tv or ;Iown/' y /Z) C E R T I r IL>i
xo y
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
32 i
Registered No.
2 FULL NAME E rr~A A*e 0£o co w'
(If deceased is a married, widowed or divorced woman, give also maiden name.)
I (If death occurred in a hospital or institution,
St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
a
jran,
rAR)
x ii i — i
f(Was deceased a
• ■iU. S. War Veteran,
[if so specify WAR)
(a)
Residence. No /..tf... Qa^ A A7 V..iirzM
(Usual place of abode) - * f (If nonresident, give city or town and State)
Length of stay: In place of death years months. /./’.days. In place of residence years., iff* months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
L.
(Month)
/0
(Pay)
/111
(Year)
4 } i il E R. E BY C E R T I F Y^, That I attended deceased from
Adi- SL... ,o j£kl < % ,,6/
I last saw h.S5L/!fIive on JbJhA S'.. , 19....&../., death is said to
have occurred on the date stated above, at ...A..UAA m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Pi dO
(b)e TYZLrV-^r/o rc~/<z r* Si S
z-
-ZJ # P j elZ"
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
T
12
AGH^Tj Years. ^....Months
^...Days
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased
If so, specify
■Qr
M °
. — /PRINT, OR TYPE SIGN^URET /
(Address/.^^.L^.X/?../^.^^.^.4^: Dat eZ../.../...£ 19 ...jfa .l
Place of Burial or Cremation
HZ..
nation j
DATE OF BURIAL ^ Z /3
(Cny or Town
FUNERAL DIRECTOR ..?!.chardson home
ADDRESS
Received and filed
48 UEAVEBE-f ARK. , LYNN
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
*
9 COLOR
hZ
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.
13 Usual
Occupation :
(Kind
during most of working life)
14 Industry
or Business: ...
15 Social Security No
16 BIRTHPLACE (City)
(State or country) ' ~
17 NAME OF // /s
FATHER 1/. /AttZ
18 BIRTHPLACE OF
FATHER (City)
(State or country)
AL9-lKt
19 MAIDEN NAME
OF
LL'E.IT ilAlur. a . j
MOTHER
20 BIRTHPLACE OF
MOTHER (City) /*}
(State or country) — vrq
10 SINGLE (write the word)
MARRIED ...
WIDOWED Wtdou/
or DIVORCED °
If under 24 hours
Hours Minutes
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed wtpi me BEFORE the bur^Sl or transit permit -qfas issued:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
* c c
ORGANIZATION AND OUTFIT
SERVICE NUMBER I
.-vio/'" '•
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the obser^ajlij
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. r r r i r'LQRi
(2) Board of Health physicians will certify to such deaths on|y[p0 tljjsVJ<»J 0 •
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.
AH
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 ii the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook-
hotel, etc. For a person who had no occupation whatever write none.
THIS IS A PERMANENT RECORD
R-302
%
Essex
(County)
..Danvers. W
(City or Town)
QIIj? (Enmmmtuiraltfi nf MaHaarljUBPtta
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Danvers
(City or Town making this return)
NoDanv.ers StateHospital.^.H^ in a hospital or institution’
Registered No. ... a.T
:urred in a hospital or institution,
its NAME instead of street and number)
2 FULL NAME... Arthur ?.* Wrlfiht.s.Q.n
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Wa:
)U. S.
(.if so
No
3 5 .....3uinfn.it Avenue... U.
e of abode)
Length of stay: In place of death years.l.l.months..2 ...days. In place of residence years months days.
(a) Residence. No....
(Usual place of abode)
(Was deceased a
S. War Veteran,
so specify WAR,..
Win.thr.op., Mass.*
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH .
February 11, 1.961
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
March % 19....6.0 to Fe.br.uary 11+., 19...6I
I last saw h.iifftive on ...J^.S.hl^U.S.ITy... ..H.fl9..0.X death is said to
have occurred on the date stated above, at 4:2.Qa .«n
8 SEX
male
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED . . .
or DIVORCED WldOWed
10a If married, wid;
HUSBAND of
lowed, or .divorced . , _
.Gnar.I.Q.t.L.e....Vi.e.s.tle.y
(Give maiden name of wife in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
..Generalized Art. erlosclerb sis
(a)
& Arteriosclerotic Hear;
disease years
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Sec o nda ry Anemia
INTERVAL
BETWEEN
ONSET AND
DEATH
(or) WIFE of..
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
years
12
AGE..!
33 . Years. Month^.Q...
..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: Archi.t.ec..tual....^ng.ine.er...
(Kind of work done during most oiworking life)
14 Industry
or Business:
15 Social Security* No.
Unknown
16 BIRTHPLACE (City)
(State or country)
linknovm
Was autopsy performed ?
What test confirmed diagnosis?
Tier
5 Was disease or injury in any way related to occupation of deceased ?
If so. specify
(Signed, Ill M p.J|«
, Hathorne , Mass^ate 2/11 /19 6>
( Address
'.vinthrop Cemetery, '.vinthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL brUary [ l^ 19 6. .
7 NAME OF
FUNERAL DIRE
ADDRESS
rTnp Alfred Marsh
Vinthrop, Mass.
17 NAME OF
FATHER
Unknown
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Unknown
England
19 MAIDEN NAME
OF MOTHER
Unknown
20 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Unknown
England
21 . , Mary E. Sheehan
( Address) Hatnorne t Mass ,
A TRUE COJ
ATTEST:
(Registrar of City or Town ^here death occurred)
date filed £ahE.uar_3L_2.Q., 19....6.I
X
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-301A
|
t f#J
UCTIONS
OR
CERTIFICATE
Jiving
OF DEATH
>t enter
:han one
for each
b) and (c)
is not mean
of dying.
eart failure,
tc. It means
, or compli- ^
hich caused
is, i) any,
we rise to
ause (a),
'■he under-
ause last.
ions contrib-
r" ath but not
the terminal
idition given
Chapter 137,
54, requires
Is to print or
I cause or
death on
|ificates, and
18, Acts of
lires Physi-
|rint or type
:r signature.
G •
59-925686
Suffolk
(County)
Win throp
(City or Town)
126 Brookfield Rd,
U>br (Unmmnuuiraltb nf lHlaaaar^UBrttH
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.
No.
St.
[(If death occurred in a hospital or institution,
1 give its NAME instead of street and number)
2 FULL NAME Rose Dl Vita ( Lampaeona)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
f (Was deceased a
U. S. War Veteran,
(if so specify WAR)
(a) Residence. No 126 BrOOkfleld Rfl .
(Usual place of abode)
Length of stay: In place of death . 10 years months
St.
(If nonresident, give city or town and State)
days. In place of residence IQ-ears months ... days.
AL CERTIFICATE OF DEATH
vz
(Day)
( ear)
F Y
That I attended deceased from
19....“..
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
Female
White
WIDOWED ui ,3
or DIVORCEDWlCiOWea
I last saw h= alive on
have occurred on the date stated above, at ... a M
19.. death is said to
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
UY'Xl C^XUSCsS
Due To
(b)
Hyy\\ bly Cor Oh y...-Qcc IiaSIoh
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of ..
_ ,(Giv*.maidwk same of wife in full)
wife oi F»ank W. Vita
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
Was autopsy performed? /m,
What test confirmed diagnosis?/!
5 Was disease or injury in an
If so, spec
'way related to oc^/patimi of deceased ? /HO
(Si
AttUr.^C^
(Address) ,
M. D.
12
AGE
.Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
"*15 Social Security No.
At Home
noner
The text goes on. The rest is in the file.