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ORM R-301A
INSTRUCTIONS
FOR
IDICAL CERTIFICATE
In giving
USE OF DEATH
do not enter
more than one
cause for each
f (a), (b) and (c)
fhis does not mean
mode oj dying,
h as heart failure,
ienia, etc. It means
disease, or compli-
ons which caused
th.
'onditions, if any,
thich gave rise to
bove cause (a),
tating the under-
pin g cause last.
Conditions contrib- .
i g to death but not
ted to the terminal
ase condition given
a).
Note:- Chapter 137,
eta of 1954, requires
tysicians to print or
pe the cause or
uses of death on
ath certificates, and
tapter 48, Acts of
59, requires Physi-
ans to print or type
ime under signature.
M-6-60-928145
T
Suffolk
(County)
.W.inthr.Q.p
(City or Town)
QHjr (Emmnmtuiraltlf nf HHaajgarliuapttH
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.
I
Registered No
No.
80 Upland Road
St
f (If death occurred in a hospital or institution,
. | give its NAME instead of street and number)
2 full name Elmer Stuart Lipsett
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 80 Upland Road st
(Usual place of abode)
PHYSICIAN — IMPORTANT
((Was deceased a
W.W.l
. iU. S. War Veteran,
(if so
so specify WAR)
Length of stay: In place of death
1L
year* months days. In place of residence years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
January
(Month)
1
(Day)
(Year)
4 1 HEREBY CERTIFY,
. 19..
.., to..
That I attended deceased from
19....TT...
I last saw hj.}?jalive on , 19 , death is said to
have occurred on the date stated above, at ...././..l. ..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
laJ.
Due To . . . —
(!"/ res Coroi
Due iTo
(c)
>// Coroner/
Occ/u
*Afte * iosderotic //e^rt P [se\ se
OTHER
SIGNIFICANT
CONDITIONS
ertejns/on
INTERVAL
BETWEEN
ONSET AND
DEATH
SuA>
«S\joYl
en
/o yrs
2
ioyrs
Was autopsy performed? (Vo
What test confirmed diagnosis ft Z~
5 Was diseas£_(>r injury^n any way related to occupation of deceased? (Vo
If so, sQ^ci:
6 Winthrop Cemetery Mnt.hr.Qp.,.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTO
January 4,1962
ADDRESS .1.7.4 IxM.h.r.o.p.....St... Winthrop.,.
Received and filed
; " ;
.19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
married marne
WIDOWED
or DIVORCED
(write the word^
10a If married, widaived, or divorced _
.Evh. Prances Barrett.
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...6.5... Years l.CXfonths2.6....Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Advertising agent.
(Kind of work done during most of working life)
or Business : .. paper. Mfg^.Co.
15 Social Security No .Vj
-.03-2352.
16 BIRTHPLACE (City)
(State or country)
Lass
17 NAME OF
father Andrew Lipsett
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
Mabel Phillips
•MOTHER (City) .
(State or country)
Maine .
Informant Mrs.* Elmer S* Lipsett
(Address) - - 80 IT pi and Road, "interop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with, ipe BEFORE thg.Jjurial' or 'transit, permit was issued:
M&SLSL. (ZL . 6.. ::/i...C... ft sjbl.-.
(Signature of Agent of Board of Health or other)
(Cffficial Designa>i€
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
bJrJlLZ.
%hMxS
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.
1RM R-301A
n "% r.i1
lii-*
V
INSTRUCTIONS
FOR
IICAL CERTIFICATE
In giving
JSE OF DEATH
do not enter
more than one
:ause for each
(a), (b) and (c)
Iris does not mean
mode of dying,
as heart failure,
’ nia , etc. It means
disease, or compli-
ns which caused
h.
mditions, ij any,
Hich gave rise to
ove cause (a),
iting the under-
ing cause last.
Conditions contrib- .
f to death but not
ed to the terminal
■se condition given
J).
>te:- Chapter 137,
i of 1954, requires
sicians to print or
the cause or
•es of death on
h certificates, and
pter 48, Acts of
, requires Physi-
s to print or type
e under signature.
10M-6-59-925686
(Tbf (Common uiraltli of HHaoaarliusrttH - ,. .
<f irtcmu n u/ a dh **
(County)
< Suffolk
p
(U,
1° winthrop
O (City or Town)
s3 no 1.7 Jnv.ia....S.tr.e..e.t
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH To be filed for burial permit
4 DIVISION OF VITAL STATISTICS with B°*rd of Health
fil or its Agent.
STANDARD
CERTIFICATE OF DEATH
Registered No.
2
((If death occurred in a hospital or institution,
St. ) give its NAME instead of street and number)
2 FULL NAME
PHYSICIAN — IMPORTANT
h-ry ft (Butler) hitehead |{fs;wXaran
(If deceased is a married, widowed or divorced woman, give also maiden name.) [if so specify WAR)
(a) Residence. No.
(Usual place of abode)
2
St.
(If nonresident, give city or town and State)
on
Length of stay: In place of death years fr... months days. In place of residence. ..E.:....years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
JTW.
(Month)
I
(Day)
1±A
(Year)
4 1 HEREBY CERTIFY,
That I attended deceased from
S? tY /. 19 1st
8 SEX
9 COLOR
Female
White
I last saw h-.t^alive on death is said to
have occurred on the date stated above, at fyT. m.
INTERVAL
BETWEEN
ONSET ANO
DEATH
l' Y/Li
DEATH WAS CAUSED BY: IMMEDIATE CAUSE -
^ —
(b)e T1 a C* m tf SCL t-U. &
3/S*
Due To
(c)
fttlr •*
OTHER . . - . , j y?
significant £ i UCu & .i ■> 4~B LJLrJL
CONDITIONS
oib
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED , . ,
or DIVORCED ..1QOW
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Alfred E Vmitehead
(Husband’s name in full)
(or) WIFE of
11 IF STILLBORN, enter that fact here.
Was autopsy performed? ..fij. t
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?/
If so, specify
m
(Signed)
...M.yjLilM M..o.J.£..Y..A/.....G~
(PRINT OR TYPE^SJGNATURE)
(PRINT OR TYPEJ5JGNATURE) .
(Address)y.L.<r... Date f/h 19.4...
6 wmthrop
Place of Burial or Cremation
DATE OF BURIAL
..uin.thr.o.p.
Jan(^ity4orTown) 62
7 NAME OF
FUNERAL
director .d.P.YI.ay.d....v .Reynolds
ADDRESS g^.Mff.OP k&SS,
Received and filed l.T!..s.l.„.(....^....„
Jr. I J o 1 '•
=•(?•« >9
(Registrar)
12 7A
AGE../... 9..
Years. ../i: Months Days
0
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
None
15 Social Security No.
moTum UT tr: s COUTltv 'JOrk
16 BIRTHPLACE (City)
(State or country) XUS-LcJICX
17 NAME OF
FATHER
/■T. T
3utler
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Ireland
19 MAIDEN NAME „ ' ' A ' * , . , «
OF MOTHER UUS.Dle GO Oot-s.Ln
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
'Ireland"
(Address) ••13-5""UeeajrT:f'.' I;mri S; ass"
a Joseph
I H
was
EREBY CERTIFY that a satisfactory standard certificate of death
filed with me BEFQRE the burial or transit permit was issued:
"i/r
l \ -
(Official Designation) (Date of Issue of Permit)
M (S W
(Signature of Agent of Board of Health or i
v
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 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.
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
50M-3-61-930213
{
SUFFOLK
(County)
WINTHROP
e Commontoealti) of iWa«8atf)usett«
(City or Town)
KEVIN H. WHITE
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.
3
400 Revere Street, Winthrop ! (If death occurred in a hospital or institution,
Xo - St. ( give its NAME instead of street and number)
2 FULL NAME
MARGARET I. SHARPE
PHYSICIAN — IMPORTANT
f ( Was deceased a
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(U. S. War Veteran,
(if so sp
specify WAR)
Me
No. LOO Revere Street,. Winthrop
(L'sual place of abode)
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
PERSONAL AND STATISTICAL PARTICULARS
3 date of January 2, 1962
9 SEX
10 COLOR
DEATH
(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.)
11 CITIZEN
OF U.S.
YES
l/ >
NOD
12 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
12a If married, widowed, or divorced
HUSBAND of
Arteriosclerotic heart disease .
(or) WIFE of
<Pe wife ir
in full)
(Husband’s name in full)
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19.
IF ACCIDENTAL, was injury causally related to the death?
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, ol
public place ?
(Specify type of place)
Manner of
Injury
(How did injury occur?)
Nature of
Injury
Job*? /Ve
20 BIRTHPLACE OF
FATHER (City) ..
(State or country)
7 Mats S
21 MAIDEN NAME
OF MOTHER
Max toe//
22 BIRTHPLACE OF
MOTHER (City) .
(State or country)
7 irs.j.nw rd
Place of Burial, or cremation.
DATE OF BURIAL
(Citjror Town)
19 62-
8 NAME OF
FUNERAL DIRECTOR
Informant .. Ufj/ham
(Address) ^
ADDRESS
/) rTbvr O'Mj/ey
tO/irThr'of) , Mass
Received and filed
u, I
A TRUE C OPY ATTEST:
.0 19..
(Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of Meath
X^X me \ burial or transit permit was issued:
■A-XX/Acc c '
/ ^-ptgfiaiure ' * '
of Agerrt ot
f
. "L ..w.L.c. *- —
(Official DeT, Li at >
!±<
/ll L
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ED
ORGANIZATION AND OUTFIT
SERVICE NUMBER
■-1 h' . -.Vr,
: I
A
o
.vy!
RULES OF PRACTICE /'. •
The fulfillment of the purpose of these laws calls for the observance of the follo^ii^i%T^s>6f practice:
(1)
Attending physicians will certify to such deaths only as those of persons tS'^wlionf' 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 <^A|)Jsii^/MQ$Iib,(',$hough disabled by
recognized disease unrelated to any form of injury, have died without recent mediea? 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.) ”
>RM R-301A
INSTRUCTIONS
FOR
ICAL CERTIFICATE
In giving
SE OF DEATH
do not enter
tore than one
ause for each
Ja), (b) and (c)
ij does not mean
mode of dying,
as heart failure,
nia, etc. It means
lisease, or compli- ^
is which caused
iditions, if any,
ich gave rise to
ve cause (a),
■ing the under-
ig cause last.
Conditions contrib- -
to death but not
d to the terminal
e condition given
ote:- Chapter 137,
s of 1954. requires
sicians to print or
: the cause or
ses of death on
th certificates, and
pter 48, Acts of
I, requires Physi-
is to print or type
lie under signature.
6-60-928145
/SB
I H
lid )
1® (County)
1 (U. ‘ ®
'°
(City or Town)
dommattwraltif nf JSaHBartfUBrttH
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 ?JL.
No. l...in.thr..c.ij ,C..Diaimj
_.(.
.1.
((If death occurred in a hospital or institution,
M
2 FULL NAME
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
ercert J j'-'inr; tt^fwceavd, a , „T ,
■'• ••«.... ( U. b. \V ar V eteran, i H- T
(First Name) (Middle Name) (Last Name) (if so specify WAR) “
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. .3.7. P .£.i.n C 6 t .Q J1 6 t. .. St. ^..*.B..QS..t.Q.n M.&SS.*
(Usual place of abode) (If nonresident, give city or town and-State)
3\ .
Length of stay: In place of death years months I. days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
( 1/tjU^ t
(Month)
/J
"(Day)"
US.
(Year)
62-
4 I HEREBY CERTIFY, That I attended deceased from
U&..G....J Lt...l.fy..lnJ. , 19..... to..x£&.XyM.{h.y....X A I9.£hf.
I last saw hl..>»,alive on .d..(X.Xi..\J...&X..!4......1z: , 19.^.ir.., death is said to
have occurred on the date stated above, at ....6>..:S..H.5^..I^... m.
8 SEX
9 COLOR
male
white
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
J vJ [ 'V*-' l CP CL J* Lj /- TO-i b 1? i l S 'Vt
#
Due To /Q
(b) UkCl H QV q
$
Oi/^C
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
fc» h - tog. t t 1 c)
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) USSUL.. Q.n.L.S U.....1?.... Un n <p^- ^ M D
- (PRINT OR TYPE SIGNATURE)
(Address)^ 2J.jT.J.)1..C,.£. . 5. f<. & Dat e.Jd+ft.i 2- I9.hicr.
6 .Clarks Harhor Nova Scotia
Place of Burial or Cremation (City or Town)
DATE OF BURIAL *[&.&.♦. 6 19.6.2...
funeral director Frederick J • Kg. grath
ADDREss32.5.....C.h.e.l.s.ea St.. E, I.o.ato.n
Received and filed ! r",i. .......7.....'.. ..Si 19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
or DivoRCErinarrjfea
10a If married, widq.wed.or divorced ,, .
husband of AiX£»r.y.Xl.i.s II«.N.i.cli.er.son..
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE7Q- .Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : .£.' Qrgffifttt
(Kind of work done during most of working life)
14 Industry , . .
or Business : . t .i XI £.Q_ . .
15 Social Security No. . 0.1.X.giiQX*"-^-6-iL"7--
16 BIRTHPLACE (City) ....C.l.£,X!ll.S EajCllO.X!
(State or country) NoVP, S COtta
17 NAME OF „ .
father Nathaniel Swimm
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
•Nova: Scotia"
19 MAIDEN NAME
OF MOTHER
Olevia Smith
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
tovd Soot ip.
2i Amaryllis Swimm
(Address) _;;7 Princeton St?. E. "os ton
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with the BJjFORE (he burial or transit) permit was issued:
(Signature of Agent of Board of HgaltJC or other)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
7730/1$
8/28/19
. Qt ate r . _ C orp s
430.6787
U.S
Army.
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 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.
V tD
FORM R-302
> v .•
£
o x
V .
u -^o
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a •- —
l« Ess©*
]Q (County)
■ -o,
)° Danvers. i
/ O (City or Town)
Qltj? (Emmnnniuniltlj of Maaflartfuartts
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Danvers
(City or Town making this ret'
No...D.a.nv.a.r.a .... State Hospital,. Mathomost.
2 FULL NAME Mary ...^.a Black (Brooks)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Registered No.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
no
(a) Residence. No.. 137 Bow.do.In Street
( Usual place of abode)
Length of stay: In place of death.... ^r... years ^.months... Olay s. In place of residence years months days.
deceased a
War Veteran,
specify WAR,
....st *inthrop , Mass..*
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
Janua ry 9 ., 1962.
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
August 20, i9 59 to January ...9.* n>. .62
I last saw hftElive on ran* 9, 19. .62 death is said to
7;Q5p„
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic heart
(a)
disease
Due To
(b) ...
Generalized Arteries clorfc sis
years
Due To
(c)
OTHER ••
significant Virus inf© ction
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
years
Was autopsy performed?
What test confirmed diagnosis?
no
days
clinical &r Labors
5 Was disease or injury in any way related to occupation of deceased ?
If so. specif
Andrew TTIchole III
(Signed) . Andrew Nichols Ill M. d
Hethorae, Mass.Date 1/9/ 19 6
(Address)
6 ./inthrop Cemetery, w inthrop
Place of Burial or Cremation .. (Cit^ or Town)
DATE OF BURIAL
T (CiW or Town) ,
January 11 , ^62
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Howard Reynolds
Winthrpp., Mass.*.
Received and filed lfL*lr ..19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED WluOW©Cl
10a If married. \^udowed_pr divqreed , r
3wej5*xiXXk1* Charles McHat ton
(Give maiden name of wife in full)
(or) wife of ...2* Fred Black
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
.9.i|pYears..l.QMonths..-.2.9>a
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Domestic.
( Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
Unknown
16 BIRTHPLACE (City)
(State or country)
Meriden
onhecticut
17 father1 1st, name unknown. Brooks
;^pyi8 birthplace of
FATHER (City) ..
(State or country)
Unknown
Unknown
19 MAIDEN NAME
ofmotherMp ry , maiden name unknown
20 BIRTHPLACE OF ...
MOTHER (City)
(State or country) UntalOWIl
21
Informant
(Address)
Geprgie T*..Brimigion
He thorn©, Megg ,
A TRUE COPY
ATTEST: /Sid
DATE FILED
re death occurred)
16..,.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
FORM R-302
£87
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X
Middlesex
.(County)
a ®1|? (Unmmnnumtltff of ffHaaaarljuarttB
joseph d. ward Cambridge
Cambridge
(City or Town)
No,
2 FULL NAME
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or Town making this return)
33
C-u&rdian Hospital
Margaret Tirana Pontiff
Registered No.
6
..St
( (If death occurred in a hospital or institution,
. ( give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
66 V»inthrop Shore Drive
(a) Residence. No
(Usual place of abode) f
o
Length of stay: In place of death years months days. In place of residence years months.
..St..
) (Was deceased a
jU. S. War Veteran.
(If nonresident, give city or town and State)
days.
MEDICAL CERTIFICATE OF DEATH
■Jl ry ! ' ' ,
3 DATE OF v ^ &,a x « i
DEATH .".
(Month) (Day)
(Year)
4 J HEREBY CE
r. • - H .
I^rpFY. That, I amende
ded deceased
19 Q" h ft
I last saw h...... alive on .'..s 19,...'.., death is said to
O T HO \ I
have occurred on the date stated above, at .'. m.
19..
VS
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Corebrnl Thrombosis with
( a ) .^.x, K:vl.,.;1^.p.ft.y|)0F.g.J..g
Due To Hypertension
(b) Z.Z.
Due To Gastric Carcinoma with
(o peri't onoaT ' T!iet a'srt'as'C'3
OTHER
SIGNIFICANT
CONDITIONS
-r±a-
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
Glinlcal
5 Was disease or injury in any way related to occupation of deceased ?
If so. specify
~ , IIo n r vr C . R ob ins on
(Signed) T „.s<^ M D
S DMA mf i 1 T ft iw. **an«13g|0
(Address) . Oiaar.v.L
‘■t, ■' .
-Aver
Place of Burial or Cremation J p p ■ py ffc'fliyyjr Town) C)P\
DATE OF BURIAL 19..
7 NAME OF
Art’ ur 0 T Haley
FUNERAL DIRECTOR frgvrS";-
ADDRESS
.1^,1.
Received and filed 7.. *r..(.-,.s ^..*....?T 19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of..
iff1
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
..Years..
13 Usual
Occupation:
T’CTT
If under 24 hours
Hours Minutes
j Kind of work done during most of working life )
14 Industry HllrAftg
or Business:
15 Social Security No ...»
16 BIRTHPLACE (City) .
(State or country)
17 SfMJL 2*5 del J • Sullivan
r A I HER
18 BIRTHPLACE OF
father (City) ....x.peiand-
(State or country)
19 maiden NAjiiargaret lurphy
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) .....T...p,A.J..^.pj.(J
( State or country)
21
3 ’ v . - .0 n e J . ? o ■ 1: i f f
. r t t v — *1"'.
SW-Pall R-l-ve-P;
ATTEST :
DATE
9
A TRUE COPY/^^-^^v'
( Registrar of City or Town where death occurred )
FILED 1.1..# 19...6.2.
*
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RM R-301A
£
4STRUCTI0NS
FOR
CAL CERTIFICATE
In giving
5E OF DEATH
10 not enter
ore than one
use for each
j), (b) and (c)
t doe s not mean
node of dying,
as heart failure,
ia, etc. It means
isease, or compli- ^
r which caused
ditions, if any,
th gave rise to
•ie cause (a),
ing the under-
g cause last.
onditions contrih- .
to death but not
l to the terminal
: condition given
■XV O'
ote:- Chapter 137,
; of 1954, requires
isicians to print or
the cause or
ies of death on
|h certificates, and
Ipter 48, Acts of
, requires Physi-
s to print or type
e under signature.
5-60-928145
*
Suffolk
(County)
ullj? (Emnmmuuraltlj nf HJasHarlfUHrttH
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.
u Bin.t.hr..o..p...
<J (City or Town)
•1-3 J
& O'
(First Name) (Middle Name) (Last Name)
Registered No.
...ft....
((If death occurred in a hospital or institution.
No -L-X-3 i"-l-€r§L3-3-Ii-fc St-® St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
f (Was deceased a
2 FULL NAME / 5*7*. rT'. S-' l.}. fU. S. War Veteran, JJO
(First Name) (Middle Name) (Last Name)' (if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 11.3 Pleasant Street.
(Usual place of abode)
..St.
Length of stay: In place of death
19
.years months ..days. In place of residence years months days.
1.9.,,
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
]S^hof Jgftvg)-/ // jIZ2
(Month)
(Day)
(Year)
4 I H E R E B Y C ERT I F Y . That I attended deceased from
A:.pjr./ J 'L7, 19&y, to 7L.&..tlV...a.}'.Y..... U^ i9.4£
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
Male
White
WIDOWED , ,
or Di\Mm<raj*>ied
I last saw hiitTalive on
have occurred on the date stated above, at
p.e,.o.., // 19.. .ZeJ..., death is said to!
DEATH WAS CAUSED BY: IMMEDIATE CAUSE ^
AA.(J.tA
thr-
(a)
Due To
(b)
ScA
/ 5
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
Was autopsy performed? /V.
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? jVb
If so, specify
(Signed)
..(. M. D
[a/. Pl/flC-fa
(PRINT OR TYPE SIGN ATUTL£)
( Address ) 0. 9S-P. C /\y X? j}ate tj. t3. . fa. „ / / 19 4. 5*
y3/9S2rtfH —
6 Ho 1 y h o o d.....C.e.rae..t..e.r v Brook, line..
Place of Burial or Cremation (City or Town)
DATE OF BURIAL J.&n.U.&ry.....l..5 19.6.2.
7 FUNERAL DIRECTOR Ar..l.h.UP J...*. .Q..!..MSilfitX..
address .W.inthr.o.p..y Mass...
Received and filed J.p, ^ .... j. . ^ . . . 'j.* .- p .0. 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
misBAND^f Grimes
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
age6.B.
Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : Me.di.cal D.o..c..t..o.r
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Boston.
Mass
17 NAME OF
father minam O'Regan
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Boston
Mass
19 MAIDEN NAME
of mother Julia Hallahan
20 BIRTHPLACE OF
MOTHER (City) BOStOn
(State or country) HrlSS
21
Informant
(Address)
/ 1 , S V ,
(Signature of Agent of Board of Health or
.Amla OjtiQuLl-
(Official Designation) (Date of Issue of Permit)
yrTLi^.^
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
ivy
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
CHIVED
JAN 151932 prr
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.
X
b
l<
SUFFOLK
/ U«
\0 (County)
L WINTHROP
fu
I <
\J (City or Town)
' 0-
je Commontoealtf) of jfHa«sae|)U6etf«
KEVIN H. WHITE
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.
8
2 FU
5t • o. I (If death occurred in a hospital or institution,
5j.BIlfl.r0P St. ( give its NAME instead of street and number)
„ PHYSICIAN — IMPORTANT
ALICE C. EAGAN
.'LL NAME ALICE C. EAGAN JCW^ ^ceased a
(First Name) (Middle Name) (Last Name) I if so snLifv WAR) /lu*
(If deceased is a married, widowed or divorced woman, give also maiden name.) ^ spec y ’ v
(a) Residence. No 5. ....^^>1*6© t St.
(Usual place of abode)
Winthrop, Massachusetts
(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 ...
January
(Montn)
.12,
(Day)
9 SEX
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.)
MtfEljoSc.L&ioTic.
Fzmal6
(or) WIFE of
n
o
PERSONAL AND STATISTICAL PARTICULARS
10 COLOR
11 CITIZEN
OF U.S.
k'/f / B
YES NOD
12 SINGLE □
MARRIED □
WIDOWED »
DIVORCED □
UNKNOWN □
12a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
?. L....... &■* ...
(misband’s name in full)
RTHPLACE (City)
ate or country) /) C/fy]
20 BIRTHPLAC:
FATHER «&«$•)
(State or country)
21 MAIDEN NAME
OF MOTHER
22 BIRTHPLACE Oi
MOTHER (City*
(State or counyy)
23 C Jfyt
Informant
! Address)
A TRUE COPY ATTEST:
vCf) 19-
(Registrar)
-•^UEREBY CrflfftFY that a satisfactory standard certificate of death
Fled wirV.f t’FFORE theAurialW trap' tied:
^
l/. •; Agent oi Koai^of Heilth or othefy '
/ %,
(Official Designation) /CD/te of Issue of ij/rmit)
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 toTVftbnl- tJily* l 2 3-raiv4^ 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 coi'onaxy sclerosis. (Sudden death.)” * •
RM R-301A
fSTRUCTIONS
FOR
SAL CERTIFICATE
In giving
JE OF DEATH
o not enter
ore than one
use for each
0, (b) and (c)
t does not mean
node oj dying,
as heart failure,
ia, etc. It means
sease, or compli- ^
i which caused
ditions, if any,
h gave rise to
>e cause (a),
mg the under-
g cause last.
onditions contrib-
to death but not '
' to the terminal
condition given
t:- Chapter 137,
>{ 19S4, requires
cians to print or
the cause or
s of death on
certificates, and
er 48, Acts of
requires Physi-
to print or type
under signature.
M-6-59-925686
cS O lL Q d (
(fcojinty)
Ut^+div'a £
(City or Town)
/Hocvit S
(Tbr (Tommatiuiralth nf fSaafiarljUBFttH
JOSEPH D WARD
( SECRETARY OF THE COMMONWEALTH
jl# DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
a
No.
C_ „ - . ~f t-f ((If death occurred in a hospital or institution,
- St. 1 give its NAME instead of street and number)
fill L Amie LucY Hurley
II NAMF. ^ ULY
vcirced
(£<(
2 FULL NAME (U. S. War Veteran
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
[(Was deceased a
U. S. War Veteran, »T
if so specify WAR) I\.Q..
(If nonresident, give city or town and State)
Length of stay: In place of death years months ' days. In place of residence^.Q years months days.
(a) Residence. No .^L....)E iC...Q..(
(Usual place of abode)
St.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T
death r January...
(Month) 17
(Day)
I.9.62.
(Y ear)
41 HEREBY C E R TIFY, That I attended deceased from
t 3. % i9^7( to Jp vi si Cl vy (7 19. 6 ^
I last saw h.S.Calive on ... J..(L)CI..M..&....)C..2^ ?. , 19...(ir.. .r:'death is said to
have occurred on the date stated above, at ..’.A. I....m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
/\r"fevio<,C'(?Yt,7Tt. n £ q. y- t
T) tec S> -e
(a)
g"eTo^)y'fevi c Sc/ev
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
5-4 r>
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
Wh ite.
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVOT
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
RCI84ngle
I Husband’s name in full)
11 IF STILLBORN, enter that fact here.
f O
/]
Was autopsy performed? .LfeSwSr .
What test confirmed diagnosis? r!
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
r j tzz
(Signed) .ylLi.
.^ra.k.vL fe
., M. D.
(PRINT OR TYPE SIGNATURE)
(Address) 2..2 Date L™...™™™ 19..“...
U, si x -.
Place of Burral or Cremation
DATE OF BURIAL
MaLderb-Ma&s -
_ (City or Town) ^ _
January 16 19 62
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
AGE. Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : ...At ,
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Boston.
Mass"
17 NAME OF
father Jeremiah Hurley
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER Am 1 <=> RflPPPt
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Breland
21
Informant
(Address)
arl.ew Blais...
Lor mg Road Wi ntbron
Arthur J o. ...0.' Haley
wmtnrop Mass
Received and filed
JAU iS ^OQn *9
(Registrar)
I HERF.B\ .CERTIFY that a satisfactory standard certificate of death
wj/filed/'with me BEFORE the burial or. transit permit was issued:
J.
AgeOt^f B
(Offi
/ , (Signature of AgenvTif Board of Health
(Official Designation) ^ (Date of Issue of Permit) [
!/j y
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
• «T.
RULES OF PRACTICE ^
The fulfillment of the purpose of these laws calls for the observance AW
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.
RM R-301A
ISTRUCTIONS
FOR
■UAL CERTIFICATE
, In giving
|>E OF DEATH
I o not enter
■ are than one
luse for each
|i), (b) and (c)
I does not mean
Inode oj dying,
lu heart failure,
l a, etc. It means
fsease, or compli- -p.
which caused
llitions, if any,
■ A gave rise to
lie cause (a),
■jig the under-
S' cause last.
additions contrib-
H‘o death but not'
I to the terminal
■ condition given
i
Ite:- Chapter 137,
ft of 1954, requires
licians to print or
I the cause or
(Its of death on
si certificates, and
Iter 48, Acts of
I requires Physi-
I to print or type
u under signature.
-60-928145
W/ty
is Suffolk
° (County) / , 5
oty? (EnmmmtutFaltlj nf f0afisarl|UBi*ttB
1° Wint.hr op
(City or Town)
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
10
No.
Winthrop Community Hospital
PHYSICIAN — IMPORTANT
2 FULL NAME
Mary R. Kidder
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
((Was deceased a
. 4U. S. War Veteran,
(if so specify WAR)
(a) Residence. No. ... 44 Majhle St., Marblehead Mass.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months 6.^. days. In place of residencew^?.. years months days.
MEDICAL CERTIFICATE OF DEATH
3 death !... January 1.7 1.9.62
(Month) (Day) (Year)
R E
I
l
Y C E R T I F yr, Tha| I attended deceased
— . iii^jP#,....^. 19......
I last saw h.e.htalive on (..*7..., 19..1..3:., death is said
have occurred on the date stated above, at .
to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Ca ...c£.uaAXn.t..£:g:.L&
E
l o
Due
(b)
c<- 1 1,1 r, /n ix
LA
Due To
(c)
OTHER ^ ^
SIGNIFICANT .#^/...QC.
CONDITIONS
— -c
INTERVAL
BETWEEN
ONSET AND
DEATH
U/ 12
AG
IHS
\ ,,
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?^
If so, specify
(Signed
— A-lAi. .(
(PRINT OR TYPE SIGNATURE) / .
( Add ress ) 1. . i. . . ^ L kZ./j. J:fir ITa te Z. . 1 9 . .
W4UJS ID.£
Place of Burial or Cremation — ' (City or Town) ^
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
CT. 19..
ADDRESS
Received and
comR (t,
/Jf& Firn (AAAAAAAA
\ filed 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
T/fmL£
9 COLOR
lA/tilTE
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE
— - (Give maiden name of wife in full)
of SL niEipAli
(Husband’s name in lull)
11 IF STILLBORN, enter that fact here.
L. Y ears. ..hf?..... Months.. /Z ..Days
If under 24 hours
Hours Minutes
Occupation: . AcMMA L££C.M/z.A.
(Kind of work done during most of working life)
or Business : I...Q. E/l zJL £lARB..L£.^..£.dh...
15 Social Security No -
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
CtiVTUes 'F X>c£
18 BIRTHPLACE OF > J RTP tp y r U Csl A
FATHER (City) /JARB.LLMAA..
(State or country) MASS
19 MAIDEN NAME
OF MOTHER
/UiajiA f~ /A/7T^s
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
JhtflR dA £Af/?'X.
'""MAS^
Informant .Aim AeMEtt 5.m£1££0..ru.
(Address) A /i/ H j/ /F iT /tA A
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
.........
(Signature of Agent of Board of Health or other)
J CcEAx.
■ ‘ ~ (Date of Issue of Permit) '
(Official Designation)
X
- \\
10 SINGLE (write the word)
MARRIED .
W I DOW E D icrfFi
or DIVORCED ' ^
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING ;^Xai£
ORGANIZATION AND OUTFIT
SERVICE NUMBER
— ..U'-vu.
m£M:'
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls* for liiei-ohsetyance of the
following rules of practice: JAIl I H IMi}/ Un
(1) Attending physicians will certify to such deaths only \ftoie-ol 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.
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON
FORM R-302
C "C ^
> a; j
I gj
S-S
' c d
to £
2 -S a*
n, -
e
Ji-C £
£ o
CO k.
cCiJ
C a,
e ~ *
cm c
O C
u ©
O ec
*ai*5
.ti c
o c o
u5E
c **
c C
— o
TJ
3 E w
|ja
j= 2
w O a
*~*5 a
o 03
<2 *C S3
3 *0 O
_ E
-r
Middlesex....
(County)
Cambridge
(City or Town)
©I? QInmmnnuipaltl) nf iSaHHarljufiFtta
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Cambridge
(City or Town making this return)
No.
M t*. Auburn Hospital St f(If death ?cc-u-r-red in a- hospital or institution.
Registered No. 91
__;urred in a hospital or
. ( give its NAME instead of street and number)
11
2 FULL NAME /(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) JU. S. War Veteran.
P» c- . . . lif so specify WAR Z1Q
Resilience. Kn. ^ 3, HnthrOp
(Usual place of abode) _ __ (If nonresident, give city or town and State)
1 - - IT a T f 20
Length of stay: In place of death years monthsrT..!....days. In place of residence I.years months days.
MEDICAL CERTIFICATE OF DEATH
S£[ehof January 20, 19.62.
( Month)
(Day)
(Year)
4 I H E
12-3
I HEREBY CERTIFY. That I attended deceased .from
■ ■ „ 1-20 ,,62
ii: 1-20 — mgz
have occurred on the date stated above, at Y..T. ®.m.
I last saw h.±.Mtl ve on
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Glioma of Brain
(a)
Q.vks
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed ? .. 191.
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ?
If so. specify
-rto
(Signed)
(Address
Samuel Lowis
, 1/75 Comm.Ave.Bo^tjon 1-21 §2
D.
Ohel Jacob Cem,
Woburn
Place of Burial or Crematioi
DATE OF BURIAL ..
on (City or Town) /
January 2T, <a o2
7 NAME OF
FUNERAL
ADDRESS
birector Beniamin Birnbach
I^G^^bln'^orr""Stvsiorcrheis't«-:
Received and filed .. : ...
.19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
V/hite
10 SINGLE
(write the word)
MARRIED^ arr^ e<i
WIDOWE8
or DIVORCED
10a If married, widowed.
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 CTI, 1
V„ V . L .. A
AG
..YearsTT. Months.77. Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Heal Estate
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
K’ftSS*
17 NAME OF. , , ,
father A onabam Yonks
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Lithuania
19 MAIDEN NAME
of mother Rose Kapulsky
20 BIRTHPLACE OF
MOTHER (City) ......r
(State or country) knu«ll_&
2! George Yorks
(Address?
A TRU
ATTE5J)/
(Registrar drCity or Town where de^th occurred)
DATE
filed Jan... 23..
.19.
62
(/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
mUtm
ORM R-301A
A'
INSTRUCTIONS
FOR
DICAL CERTIFICATE
In giving
USE OF DEATH
do not enter
more than one
cause for each
(a), (b) and (c)
his does not mean
mode of dying,
as heart failure,
enia, etc. It means
disease, or compli-
ms which caused
h.
onditions, if any,
hich gave rise to
>ove cause (a),
ating the under-
ing cause last.
Conditions contrib- .
mg to death but not ^
ed to the terminal
lse condition given
a).
I te:- Chapter 137,
of 1954, requires
icians to print or
the cause or
es of death on
1 certificates, and
>ter 48, Acts of
requires Physi-
to print or type
under signature.
0M-1X-59-926662
(Utj? (Eflmmflmuealtij of HaHflarfjuarttB
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
i. 2
No. St. |(If dea*h -°-CC-Ur-d ^ a- h°-Spital °r '•S,ltU,i°n'
2 FULL NAME.
give its NAME instead of street and number)
y L- PHYSICIAN — IMPORTANT
— |
U. S. War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) (if so specify WAR)
(a) Residence. No. fc. 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 ^ ± If
DEATH
(Month) (Day)
M
(Year)
4 1 HEREBY CERT IF Y , That I attended deceased bm
TA W s 19 Ck.„ to AY 19M.
I last saw hi.W^alive on ... .....J. .ti.V*.. ... * 19C.1*. .... death is said to
x r 10
have occurred on the date stated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Acof-e tjiArt) Jhfj;
I,uc To J\cu (r oi} ft*‘T
t r^erJuy r-'H-
(b)
T~ 1 Si
Due To
(c)
h K D 1 a
OTHER
SIGNIFICANT
CONDITIONS
Nx pit> 4/ **£ v c/u+g l,
^ <T-— r
v111 a
INTERVAL
BETWEEN
ONSET AND
DEATH
\cA
XL
A-f_
Was autopsy performe*
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
W, Hit C" 6-Uiiri'-', iM'tP
(PRINT OR TYPE SIGNATURE)
(Address) Date L.J±. .19.
M. D.
.,^QrrA^.c.i&r.kr;^.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .rf..S*Z?.. 19.^..“
7 NAME OF
FUNERAL DIRECTO
ADDRESS
...£.
Received and filed
^-2S-m2 19"
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
11/
10 SINGLE (write the word)
MARRIED JP*- S
W+HHWE!)
or-DIVORCED y
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
O
1.8.
Years. ..Sr' Months,
11...
Days
If under 24 hours
Hours Minutes
13 Occupation:
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No
16 BIRTHPLACE (City)
(State or country)
17
F.VIH lacin'
s-ft- c
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Informant
(Address)
meat
I HEREBY CERTIFY that a satisfactory standard certificate of death
BEFOJJE the burial or transit permit was issued:
was filed with
^ , l'' (Signature of Agent of Board of Health or other )
A? Jy p/sk. / f
(Official Designation) ' (Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ORM R-301A
&
INSTRUCTIONS
FOR
DICAL CERTIFICATE
In giving
rSE OF DEATH
do not enter
more than one
cause for each
(a), (b) and (c)
his does not mean
mode of dying,
as heart failure,
nia, etc. It means
disease, or compli- -p.
' — which caused
mnditions, if any.
Which gave rise to
Hone cause (a),
Biting the under-
Wing cause last.
H Conditions contrib-
it ; to death but not ^
ehd to the terminal
jfl se condition given
<m).
■Ite : - Chapter 137,
of 1954, requires
’■icians to print or
the cause or
Is of death on
certificates, and
flter 48, Acts of
>5 requires Physi-
fl to print or type
■ under signature.
lOM-11-5 9-926662
(£nmmmtut?altfj of MafiHarljUHPttH
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.
IS
Sc.
(City or yown) ^
v/, rZ, sf 1^. {(If death occurred in a hospital or institution,
No. St. ( give its NAME instead of street and number)
2 FULL 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)
(a) Residence. No
(Usual place of abode)
.St.
Length of stay: In place of death years months days. In place of residence..
(If nonresident, give city or town and State)
..years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF -yy ft ^ V
DEATH J... r,U. — , 11.1*
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, That I attended deceased
'XAMsA*- 19.C.«L.„ ,o ~XAU wM.
I last saw hi.Lwalive on ..._....J...A.W....J?V , 19&k...... death is said to
' r SO
have occurred on the date stated above, at ..#£... A m-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Ac o{-Z lr <? -f <i
|b]e T° Acv k /» fut-y ftj t
Due To
(C)
NKD ) A
iUGNTFICANT l 1 L'
CONDITIONS
Te
LLL
Was autopsy performed
What test confirmed diagnosis?
M
INTERVAL
BETWEEN
ONSET AND
DEATH
A-f_
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
*‘f i /( i d iv « hi iM .<£>•
(PRINT OR TYPE SIGNATURE)
... M. 1).
(Address) Date..
..L.Jl.M.k’t.
6.xr
Place of Burial or Cremation
7 NAME OF
FUNERAL DIRECTO
natroi
&
■JrrA.^r.L.I&CkC.fCr.:.
(City or Town)
DATE OF BURIAL M.StZ?. Imcr.. r. 19.1
ADDRESS
....£.
Received and filed
gb
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
})vz£q_ i// juJ%L^
10 SINGLE (write the word)
MA-RETED P.
WIDOWED ^
or-DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
O
18
Years..?nr Months./..*^..... Days
If under 24 hours
Hours Minutes
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No
16 BIRTHPLACE (City)
(State or country)
17
F ATH <_ /y x££g~
e-rt- C
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Informant
(Address)
C< /cu. u. '1 < --i
I HEREBY CERTIFY that
meat
satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
: ,
(Signature of Agent of Board of Health or 9ther)
X
fcd..ddC:...C-..L:~ '
(Official Designation) (Date of Issue of Permit
ue of I
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
T"0
O '
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for
following rules of practice:
* (1) Attending physicians will certify to such deaths only as those of persons
to whom they have giver, 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
jiersons 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 irerson 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.
ORM R-302
o «
g a
Q w
tar ►«
£ *
« H
« I
O M
h fc
Q ~
w M
> «
« 5
h
OT M
« O
* s
M
£ °
5 <
M (X
“ g
» P
H
H
*
CT3
> 4/
» (/)>
5 rt
5^0
i»2
'S-c
4>xf*
X.u^
ox«
C **
rt
C.5 &
•o cU
£ * a;
^ O 4/
M ♦'C/J
o >, I
</> *- l
<« - :
a> ° (
-0 4/
•c
u _v
«*T 4/
* Jx
u — *-
' v.±
*
O O -
>%h, c
o
“iE
3
on. -5
__ X
3^ 2
x *; s
3 E 4/
U <£X
o c -
IJ5*
w2ii
£ 3X
<« 2’35
41 x ^
&
v~X
: o o
:§
z
:xt
x
®ljp (ComittnnuipaItl| of fHaHaarljufifttn
Essex
(County)
Lynn
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town)
Sk
(City or Town making this return)
COPY OF
CERTIFICATE OF DEATH
Registered No.
.JLsjfc
No Lynnvlew Hospital St.
VoT.WjBfc.. Utti&Z / tt j. • \
2 full name Anne Piper ( Hart in).,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
((If death occurred in a hospital or institution,
I give its NAME instead of street and number)
(a) Residence. No .9.7 Washington Avenue
(Usual place of abode)
St..
(Was deceased a
U. S. War Veteran,
if so specify WAR)
M.nthr.o.p.
(If nonresident, give city or town and Stpte)
Length of stay: In place of death years.....^...months days. In place of residence. ,.S.Vyears months days.
MEDICAL CERTIFICATE OF DEATH
DEATH January ...29,1962
(Month) (Day) (Year)
4 I HEREBY CERTIFY
That I attended deceased from
19....
Jan. 8 ( 19 62 t0 Jan . 29/62 _
I last saw h ® ©ive on ... Jan.. 2.7762. 19 death is said to
have occurred on the date stated above, all..* 20 a
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Adenocarcinoma of pancrea ^ DEA™
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
1 JTj
Was autopsy performed?
What test confirmed diagnosis?..
no
clinical..
5 Was disease or injury in any way related to occupation of deceased ?.I1Q...
If so, specify
Clarence London „ n
(Signed) - , M. D
(Address)
Lynnview Hosp. Date 1/29/ 62s
e Eoreet. Hill s Bos ton
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ^LpUary 1/62 19..
7 NAME OF
FUNERAL
DIRECTOR ... Maurice W, .Kirby.
address Iin.thr.op., Mass,
Received and filed '.7.
1
.19..
(Registrar of City or Town where deceased resided)
8 SEX
9 COLOR
female
white
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED iwt 4 m
WIDOWED W10.0W
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of..
(Give maiden name of wife
Harold *». Piper
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 68 Years .jr.. Months.. .Q Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:..
Clerk
(Kind of work done during most of working life)
14 industry
or Business:
Town Hall, Win thro p
15 Social Security No..
6 BIRTHPLACE (City). .
Bo st on ^
(State or country)
Mass.
17 NAME OF
FATHER
John J. Hart in
18 BIRTHPLACE OF
FATHER ( City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Elizabeth MeElroy
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Boston
Mass.
21 T , .Miss Virginia Keeler
Informant. H- ...........T.
(Address) Bav-Olon— JicL- . Mil t on .
A TRUE COPY
ATTEST:
I
(Registrar of City or Town where d<Ath occurred)
DATE FILED ... ...Jan., 31/62 19. _
i/.ftl/
.
STRUCTIONS
FOR
AL CERTIFICATE
In giving
E OF DEATH
■ j) not enter
I re than one
kise for each
I), (b) and (c)
I does not mean
I ode of dying,
I I heart failure,
etc. It means
ease, or compli- .
which caused
\itions, if any,
i gave rise to
cause (a),
•g the under-
cause last.
—nditions contrib- .
i fo death but not ^
to the terminal
condition given
e:- Chapter 137,
itof 1954, requires
cians to print or
the cause or
of death on
certificates, and
:er 48, Acts of
requires Physi-
to print or type
under signature.
1160-928145
4
L
3 Suffolk
I® (County)
(O'
lO
L lint.hr. op
fu (City or Tc
town)
Qhmunnmuraltlj nf MaHaadjuartta
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
Tin,, \T. i T\Jn-K»ca-i y, rr n HIf. death occurred in a hospital or institution,
No JU?.C Xj. Y.X.C.YV. St. | give its NAME instead of street and number)
2 full name Edward Everett Sargent ( U. S. War Veteran
(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
-1 U. S. War Veteran. IN U #
(if so specify WAR)
7a) Residence. No. ~zr:195 Winthrop Street st
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay; In place of death 1 years 9 months days. In place of residence .. 4 Pears months days.
MEDICAL CERTIFICATE OF DEATH
3 death F. February 4 1962
(Month) (Day) (Y ear)
4 1 HEREBY CERTIF Y , , That I attended deceased fron
February 16 ; 19 ol to February 4, 19 o2
I last saw kliq. alive oFebr.uary..3.r_ 19. .6.2.. ., death is said to
7:55 a
have occurred on the date stated above, at ...........™.„.....“..°..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic & hypertensive
(a) Heart Disease
(b)e Generalized arteriosclerosis
Due To
(c)
other Prostatic hypertrophy
SIGNIFICANT .7.1.
CONDITIONS
^0
INTERVAL
BETWEEN
ONSET AND
_ DEATH
2 yrs.
3 yrs
3 yrs
Was autopsy performed?
What test confirmed diagnosis?
Clinical & Laboratory
5 Was disease or injury in any way related to occupation of deceased? ..N.O.,
If so, specify
(Signed)
(Address)
M. Traunstein, 'Jr. , >I7D. f
73 BarSlir I^PE SIGNAWh’
Winthrop. 52 , Massachus etts
Woo diawn Cemetery Everett, Hass .
PlaCeCtieeffldrfiTOn (City or Town)
Feb;
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS 1.74 Wint.
Received and filed ... F£B6 4962
.19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
10a If married,
HUSBAND of
white
10 SINGLE (write the word)
wimwed married
or DIVORCED
iyorced •
Rose Andrews
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE 92Ye
.3. Months.. 1.5. ..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
retired printer
(Kind of work done during most of working life)
14 onrdBus7nesS oumier cial.. 2r inting. C.o.«
15 Social Security No.
.0.23-16-9856.
i6 birthplace (city) Haverhill
(State or country) .Sft COhn S e 1 1 S
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) .
(State or country)
David Pills ivin^y Serpent
Haverhill
Massachusetts
19 MAIDEN NAME
OF MOTHER
E. Eartlett May
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Haverh ill, Ma§,s,v>
- ~ . - ’ o ; » «
Informant
(Address)
Mrs.* Edwar.d...E.» Sargent
Winthrop Et . TWi nthrop-
I HEREBY CB
was filed with n
ITIFY that a satisfactory standard certificate of death
BEFORE the, burial or transit permit was issued:
^
o.p.....S.t..« .Win.thr..o.p., flas.su
(Signature^ of Agent of Board of Health or other)
(Official Designation) (Date of Issue of Permit/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice: r r ipA
(1) Attending physicians will certify to such deaths only as those fifj>ersons :
to whom they have given bedside care during a last illness from disease utT-
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.
r.i
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
■m CERTIFICATE
I In giving
OF DEATH
not enter
re than one
c se for each
), (b) and (c)
I does not mean
lode o) dying,
heart failure,
li, etc. It means
hose, or compli- ^
1 which caused
\<tions, if any,
gave rise to
cause (a),
g the under-
cause last.
Ciditions contrih- .
f > death but not
a to the terminal
ij. condition given
Ve:- Chapter 137,
t if 1954, requires
#cians to print or
■ the cause or
ut> of death on
t er 48, Acts of
certificates, and
requires Physi-
to print or type
tinder signature.
.
0-928145
<
Suffolk.
(County)
iu .Winihrop
O (City or Town)
..153 Cliff Avenue.
(City
No.
(3% (Unmmnnuipalttj uf MafiaarljufitfttH
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.
1 5
f (If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME
, Jo. -L&-V
Belinda .Yvonne Waldron \‘...
(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,
lif
so specify WAR)
(a) Residence. No. 133 Cliff AVenUe
(Usual place of abode)
..St.
Length of stay: In place of death
18)
(If nonresident, give city or town and State)
ears months days. In place of residence 18 ..years months days.
MEDICAL CERTIFICATE OF DEATH
3 death! February..
(Month)
5.
(Day)
1.9.62.
(Y ear)
4 1 HEREBY CERTIF Y, That I attended deceased from
/J 19 i£4L, to .A i9i..n.
I last saw h<£?.valive on death is said to
have occurred on the date stated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) A
Due To
(b) /ffz rr c/t So, E£cS/ s
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
t.
INTERVAL
BETWEEN
ONSET AND
DEATH
-&/te>
Was autopsy performed? fv..S.
What test confirmed diagnosis? ..
5 Was disease or injury in any way related to occupation of deceased ?^f?
If so, specify
1e^rMerr..J. 7
(Signed)
( PRINT OR TYPE SIGNATURE)
M. D
( Address) . . . Date 19.^..
6 HolyHood. . Cemetery .^Brookline
Place of Burial or Cremation (City or Town)
date of burial February 8,196.2 19 /
ADDRESS 174 Wisthrop St. Winthr.o.p..,.
Received and filed
FEB * 1962
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (Aviate the word) ,
married divorced
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Harold Evans
(Husband’s name in full)
(or) WIFE of
11 IF STILLBORN, enter that fact here.
12 r r\
AGE Due
13 Usual
Occupation:
...9 Months. .1 Q.Da^s
tTF
If under 24 hours
Hours Minutes
..h.Q.uae.wQ*fe.
(Kind of work done during most of working life)
14 Industry
or Business:
..own. ...home.
15 Social Security No.
...none...
16 BIRTHPLACE (City)
lew.Ior]
£ Citv
(State or country)
ew Yor
c
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) .
(State or country)
Charles Henry Waldron.
.Utica
New York
19 MAIDEN NAME
OF MOTHER
Florence Viotonia
20 BIRTHPLACE OF
MOTHER (City) N.S..W..... York City...
(State or country) New York
JlolarT
Informant
(Address)
c¥i^a^ve^intPi¥op f Mas s ,
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with, me BEFORE the burial or transit permit was issued:
Mass... 1 ...ZZt.v
. X (Signature of Agent of Board of Health or other)
(Signature of Agent of Board or tteaitn or otner;
U : .Z
(Official Designation) (Date of Issue of Permit)
(Date i
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 I 1 _ i .
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.
t RM R-301
ISTRUCTIONS
FOR
■ AL CERTIFICATE
In giving
E OF DEATH
not enter
|re than one
ise for each
|i), (b) and (c)
does not mean
]j ode of dying,
|t heart failure,
etc. It means
bare, or compli- ^
which caused
\Uions, if any,
gave rise to
cause (a),
; the under-
cause last.
JiJitions contrib- _
p death but not
I/O the terminal
fcondition given
e:- Chapter 137,
of 1954 requires
licians to print or
■ the cause or
Is of death on
I certificates, and
uter 48, Acts of
I requires Physi-
•I to print or type
r under signature.
§61-930213
i
ZSoF-FolK,.
(County)
(City or Town)
No. J. A.
Qlmnmmtuiraltlj rtf MafiBarljUHrtta
KEVIN H. WHITE
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 3
^8
A. /X&.l/X. tt At. A..AA.. S j^' occurr^ *n a. hospital or institution,
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
fi'll name MIMS £ ,M U £ PHY !'„*!! tert&L, „ .
(First Name) (Middle Name) (Last Name) (if so specify WAR) ..II...M.?.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. /.A (/ A Jt/Z/Z' At A A..
(Usual place of abode)
..St.
Length of stay: In place of death.
A
years months days. In place of residence.
MEDICAL CERTIFICATE OF DEATH
3 death017. February 7* 1962
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
March 17, , Feb. X* 19....62.
I last saw hi.™. alive on ... Feb... 5».., 1(62.... ., death is said to
have occurred on the date stated above, at ...2..f...b.Q.....B.».m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Arteriosclero & Jtiypertensiy e
heart disease
Due Generalized arteriosclerosis
(b)
Due To
(c)
sinNiFTCAYT Carcinoma of pharynx
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
X
2 yrs
3 yrs
Was autopsy performed? *.v v
What test confirmed diagnosis? & l^0r^.°IL
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
TICT
(Signed) .
M. D.
(Address)
73 BarPtTe|tTyKdN>me) Feb. 8, 62
Wiaffirop 52 , M-assP3^ »9
6 Ar./.U/fz PMc/yfszA'
Place of Burial or Cremation (City or Town)
DATE OF BURIAL t.O
FUNERAL DIRECTOR Af 4 AA. AA /if. //?..& At...
ADDRESS 4A../Z/.7t.SZ/A.6./?t....
Received and filed
FEB ' 1361
.19..
A TRUE COPY ATTEST:
(Registrar)
13
AGE^# Years
A
(If nonresident, give city or town and State)
years months days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MUM
9 COLOR
10 CITIZEN
11 SINGLE
OF U.S.
MARRIED |
YES NO □
WIDOWED |
DIVORCED
UNKNOWN
lla If married, widowed, or divorced , _ _ . .
HUSBAND of MA..&Y... At.
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 DATE OF BIRTH
If under 24 hours
Hours Minutes
14 Usual
Occupation:
PftSS SIM.. 1
(Kind of work done during most of working life)
or Business:
16 Social Security No 6.AL..Z.C..Z...-.
17 BIRTHPLACE (City) ...A.A.. ....
(State or country)
18 NAME OF
FATHER <7 0 A/S
A?J P,
19 BIRTHPLACE OF
FATHER (City) ....
(State or country)
sr._
a
x/ f A/S
W~'
20 MAIDEN NAME
OF MOTHER AC/f^ A
0 J {-/-///At.
21 BIRTHPLACE OF r -r- , , es
MOTHER (City) A.L...„.A.A...tt..SA.....
(State or country) ^
“ Informant Af.AA..
(Address) /tf AZA/tvA At A At
'.4...//, ±4 ij±y...
I^HEREBY CERTIFY that a satisfactory standard certificate of death
vras filed with me BEFORE the burial or transit permit was issued:
-
(Signature of Agent of Board of Health of other)
I
fficial Designation) ' (Date of Issue of Permit) ,/ f
Vil.iY
(Official
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 physician* will certify to such deaths only as those of, persons
to whom they have given bedside care during a last illness front 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. r ,
(3) Medical Examiners will investigate and certify to all deathsj'stjpposably ' -J
due to injury. These include not only deaths caused directly or indirectly by- J- 1
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.
X
M i Idlosox
Cnnb^r^o
(City or Town)
®he Commontnealtlj of Massachusetts
KEVIN H. WHITE
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER'S
CERTIFICATE OF DEATH
(City or town making return)
Registered No.
..2.05.
Fin nn fn 4*n r, (M tn UnflP „ J(H death occurred in a hospital or ir
No. A...V?..:.-...it..Q .M.lf. .‘■.r'.F ....... — St. ) give its NAME instead of street and number)
institution,
Albert freffin
f (Was deceased a
2 FULL NAME ... ..:.... - (U. S. War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) (if so specify WAR)
..no..
(a) Residence. No. C?. 1.
(Usual place of abode)
••fc-vea-tte-
..St.
and State)
Length of stay : In place of death years montK£. days. In place of residence. years months days.
17
MEDICAL CERTIFICATE OF DEATH
3 DEATH^..... ^:-.r -Fj 1.0.6.2
(Month) (Day) (Year)
4 I 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.)
Arteriosclerotic Heart Disease wi
hyoert e n.a ion and auricular fibril^
Sudden Death.
1 h
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR
11 CITIZEN
OF U.S.
12 SINGLE
MARRIED
WIDOWED
ft
i.ale
•vhite
YES □ NOD
DIVORCED
UNKNOWN
0
12a If married, widowed, or divorced. - .
husband of :.iQL..e. ai.a.L.c.ri
(Give maiden name of wife in full)
a<tfl Wz o{
(Husband’s name in full)
13 DATE OF BIRTH
S Accident, suicide, or homicide (specify) ....
Date and hour of injury 19..
If accidental, was injury causally related to the death?
14 ( ft
AGE
ears Months Days
If under 24 hours
Hours Minutes
15 Usual
Occupation :
Where did
Injury occur?
....Sttltfibass
(Kind of work done during most of working life)
16 Industry » ■» , ,
or Business: v._
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in
public place ?
Manner of
(How did injury occur?)
17 Social Security No 0 , ~ . J • t — ■ ). [ m ^ :
(Specify type of place)
18 BIRTHPLACE (City)
(State or country) rblflfl l fl
Injury
Nature of
Injury
While at work ? Was autopsy performed ?
-ry..;..
6 Was disease or injury in any way related to occupation of deceased?..
If so, specif £■<
Defer
(Signed) M- D
(Address) Bate.-..? 19...
cik- * lL
Ha«» .W . Klrial It TYikawaa z Coin'i (DWvoFafct
DATE OF BURIAL 19...,
19 NAME OF
FATHER I 8&*C ' fin
20 BIRTHPLACE OF
FATHER (City) ..
(State or country)
21 MAIDEN NAME
OF MOTHER Qumot
;e learned
22 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
23
i a.
8 NAME OF
FUNERAL DIRECTOR
tt;
Informant LQC.fi
(Address) ' . \. ..7 -p ,
JE
♦ s
T“ rf Service'
ADDRESS
C'seleea,
Received and filed 19.
- _ , - M4K..5 1962
(Registrar of City or Town where deceased resided)
A TRU
l4TC6sr/ Jdz
(Registrar of City or Town where deafh occurred)
rred)
DATE FILED Feb, 13, ,,.6.2...
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
tM R-301A
jiTRUCTIONS
FOR
|\L CERTIFICATE
n giving
l£ OF DEATH
not enter
e than one
!se for each
i, (b) and (c)
'does not mean
ode oj dying,
It heart failure,
etc. It means
iase, or compli- ^
1 which caused
tions, if any,
gave rise to
cause (a),
the under-
cause last.
[ditions contrib- .
death but not
Vo the terminal
condition given
W| Chapter 137,
t« f 1954, requires
tians to print or
:he cause or
of death on
ertificates, and
48, Acts of
SR-equires Physi-
o print or type
inder signature.
u
'f
i
Suffolk
(County)
(Enmmonuiraltfj nf MafiaarljuarttH
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.
18
Winthrop
(City or Town)
Tr. . _ , . _ ((If death occurred in a hospital or institution.
No. ...Vkintnr.O.p C.Orar^U.n.Xty--- HO-Spi t3l St. 1 give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name E.r.s.nk ...A.*... Kelly (U. S. War Veteran, p
(First Name) (Middle Name) (Last Name) (if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 102 Pleasant 3t
(Usual place of abode)
Length of stay: In place of death
st Winthrop
(If nonresident, give city or town and State)
years., 1 months... 10 days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February 13 f 1962
(Month) (Day) (Year)
4 1 HEREBY CERTIFY
_ , That I attended deceased from
Jan. 2, 19.6.2... to. E|b,. 11, 19...62
I last saw hljUalive on F.^V.a...l2.> , 19 , death is said to
have occurred on the date stated above, at 7..».3.5....Am.
8 SEX
9 COLOR
M
’White
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To .
(b) cirrhosis of Liver
Due To
(c)
OTHER - , . t . . ,
significant . Diabetes ...Mellitus
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
3 Mos
3 y e< Social Security No.
Clinical Findings
Was autopsy performed? No
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? N.Q..
If so, specify ...,
rdriSc..
s9^TlHuf) ’ ^ ^ ‘
M. D
(PRINT OR TYPE SIGNATURE)''
(Address) ... Revere.*. ..Mass.. Date Feb. 13 >19°^
eM.t... ,C.sl.s/..ar.y.., M.a.t.fc.s.pan
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL iQ.h.j* 16.., 196.2...
7 NAME OF '* 4- /s ^ v* n tt* •
FUNERAL DIRECTOR J&M H. 1^^.1113
address 2 Meponset Ave.. Dor Chester-
Received and filed
FEB 14 Wl
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED Mcr- r 1 P'i
WIDOWED
or DIVORCED
10a If married, widowed, or divorcedr , . m„._
husband of : ,E..». Trsvers...
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
age6..7„... ..Years Months Days
If under 24 hours
Hours Minutes
13 Usual
occupation: .T.mne.l Mp.lQ.y.e..e.., r..e...t.i.r.e.d....
(Kind of work done during most of working life)
14 Industry
or Business:
16 BIRTHPLACE (City) B.Q..8..t..QIL
(State or country)
LT a s ;
17 NAME OF
FATHER
Arsenius Kellv
18 BIRTHPLACE OF
FATHER (City) 1.8..S..t.....B..Q.S..fc.Q.n..
(State or country) l'T & 3 S •
19 MAIDEN NAME
of mother Helen C. Lesley
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
New York
Informant ...:..I.X!..3...* Ilia li.« l.-Cll-V.
(Address) ~| OP Hpp.s on F- ,c-t . 1 El r.h ro 0
REBY CERTIFY that a /Satisfactory standard certificate of death
led with me BFJftJRE the rburial of transit permit was issued:
/(Sigl
. . LJ. .‘r'4/
(Official Designatioi
(Signature of Agent of Board of Health or bther)
;
Designation) j (Date of Issue of Permit) / j a /
v U
0-928145
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE S 6.,... 191 a...
DATE OF DISCHARGE
RANK, RATING ...P.r.i.vata
ORGANIZATION AND OUTFIT..!.?. t...C.P. a.,... BQ.S.t.Qn...S.».. .C.« A MX
SERVICE NUMBER 4903214
EC E! v E D
FEB 141962 Ml
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 injuyy.
(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 ol 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-302
C’C-
l SJ
O eC
Xi .
0'S .
£jr
S-CM
15
i*5
•§ o v
"O ^*c
$+? *
71 O U
a, ^
^ 4> o
4^j= "
-o g
<-■5 n
o a
0) to
to "0 :C
3 0 0
J.S
_ S «
M X> ?
.“£■§
o “
8m
Middlesex
(County)
A
Everett
(City or Town)
Woodlawn Manor Hursing Home
®lf? (Unmmnnuipaltlj of MaaaarljuaFtta
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.
39
No..
..St.
1 (If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME G.eO.rg.©..,^ /(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) TU. S. War Veteran.
\if so specify WAR,
(a) Residence. No. 10^.... .5. ir.C U it R Oad gf. WinthTOp, fosS..
(Usual place of abode)
Ho
Length of stay: In place of death years months.
3.
days. In place of residence3.Q... years. months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 dea?hof. February 13, 1962
( Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Jan. 1 19.62 to F©br^ry
I last saw lir.n^ali ve on .!?.? H. 13l9.t!.2, death is said to
have occurred on the date stated above, at .9*. 3.5L..Pn.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic Heart
(a)
Disease
Due
(b)
^Generalized
A^t or ids cl ends is
Due To _
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
1 yeai .
Was
What
autopsy performed? H Q-.j.. . .... .. j.j. . .. w..
test confirmed diagnosis? .1... .tihO. iMgS
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
igriaiU ..~.9..bp,...i..j». Cp3.1.1li.S, M. D.
,22 mmfMSt-’ D.,,. F e b, 14„62
(Si
(Address)
6 Win throp Ceme t.e ry, Winthrop
Piace of Burial or Cremation ' (City or Town)
DATE OF BURIAL lfe3...
7 ‘funerai. director P. ..V^aley ... Fun er al...Homf
ADDRESS .. Win.thr.Qp., Mass.*
MAR 7 1562 ,.b*
Received and filed
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
wale
9 COLOR
White
10 SINGLE (write the word)
MARRIED i,r j j j
widowed W id owed
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of..
Anna F. Croak
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.. yy. Years..” ...Months..
80
.Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Dentist
( Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
Hone.
16 BIRTHPLACE (City)
(State or country)
t d.Q.s.t.o.n...
ass,
17 NAME OF ,
father Ldward Mahoney
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Ireland
19 MAIDEN NAME
of mother Frances A. Walsh
20 BIRTHPLACE OF
MOTHER (City) ...E&.S.t... BOStOn..
(State or country) Mass.
21
Informant
(Address)
A TRUE COP
ATTEST:
DATE FILED
Ircult Rd , Wjn throp , Mas s
uary lb.
.19..
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
M R-301A
!-
II TRUCTIONS
FOR
II L CERTIFICATE
It giving
r« OF DEATH
I not enter
le than one
le for each
(t (b) and (c)
Jioes not mean
de o) dying,
heart failure,
etc. It means
ise, or compli-
which caused
scions, ij any,
■ gave rise to
1 cause (a),
the under-
cause last.
' I .
Utions contrib- _
death but not
) the terminal
ondition given
Chapter 137,
■1954, requires
ns to print or
cause or
jf death on
I'tificates, and
48, Acts of
]uires Physi-
»)rint or type
er signature.
I
-59-925686
MEDICAL CERTIFICATE OF
DEATH
3 DATE OF FT*. U
DEATH I X..... Q
Li...,
(Month)
d T HFWFRV P TT I? T T
(Day)
V V TVs of
(Vear)
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No
m
((If death occurred in a hospital or institution,
I give its NAME instead of street and number)
2 FULL NAME...
PHYSICIAN — IMPORTANT
~ /ft ((Was deceased a
\ U. S. War Veteran, L „
(If deceased is a married, widowed or divorced woman, give also maiden name.) (if so specify WAR) .t'.St’
(a) Residence. No. £3Z
(Usual place of abode) / ^
St.
Length of stay: In place of death
years.
months
Jo
£j(jOl*L£ Ot.
(If nonresident, give city or town and State)
days In place of residence. years. months . days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 'SIX! .LE (write the word)
MARK HM7 - ), V
W+DOWED tl/Mtjy- U-CtV
or DIVORCED
I last saw h.vj^ilive on f~&- t>. .2 / ‘f’. , 19 (p i-7-death is said to
have occurred on the date stated above, at ./v l. ^O ^.t m.
INTERVAL
BETWEEN
ONSET AND
DEATH
7)yj
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) P^wl 6 1 0 UP p A V l JLy S * h, U )
1 1 1 e r ' ? 1
Due To
(b)
1
Due To
(c)
SIGNIFICANT A V /.g.Y.jL.0 5 t 1 €. ¥!.C...S..t{5. .
IQ
CONDITIONS 1 '
What test confirmed diagnosis? .Q^.j. .1. Pl.t.. C-lf.. J
10a If married, widowed, or divorced E, £ ,
HUSBAND of
(Give maidenyname of wife in ful J3
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AG E/.. Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
. <L
(Kind of work done during most of working life)
"
15 Social Security No. ...(^)..Q..J...rrrr. ■)* ■/. y
5 Was disease or injury in any way related to occupation of deceased? A/.
If so, specify *
M. D.
» L C / . n'n -tO ,i.i A a/
(Signed) UJFT. .
v.^.A. !?.
(PRINT OR TYPE SIGNATURE) , /
(Address) WJ..A/...XZ.i.iA Date. Sl/ !M j
Place of Bun^rt or Cremation-^ ^ ~ (City or Town)
, . (City or lown)
DATE OF BURIAL / J 19^
7 FUNERAL DIRECTOR Jt'4' A-
ADDRESS
Received and filed
FE8 15 1962
(Registrar)
16 BIRTHPLACE (City)
(State or country)
17 NAME OF /)/ / /
FATHER
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
‘ Informant
(Address) L-S~
<<<_
I HEREBY CERTIFY that a satisfactory standard certificate of death
wa^jHei'noth me BEFORE .the burial or transit- permit was issued:
^ /LU. li-
(Signature of Agent-of Board of Heaittt-or <5Ther)
(Date of Issue of Perinit) / ,
/U X
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
R £ C £ ! V- [i D
The fulfillment of the purpose of these laws calls for the observance of theCCIl "1 C |Q|-i7
following rules of practice: FLU A V
(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.
>M R-301A
II TRUCTIONS
FOR
II L CERTIFICATE
ii giving
« OF DEATH
d not enter
m : than one
lie for each
(s (b) and (c)
isloes not mean
lie uj dying,
1 heart failure,
* etc. It means
Hi\se, or compli-
u which caused
1
naons, if any,
ictgave rise to
cause (a),
la the under-
ng cause last.
j itions contrib- .
\death but not ^
the terminal
\mdition given
at - Chapter 137.
si 1954. requires
/Ri ans to print or
elhe cause or
se of death on
th irtificates, and
'ft 48, Acts of
9 i quires Physi-
print or type
a* ider signature.
•fc'
928145
„S.uf.I.Q.lk /!£/.
(County)
..Win.thr.orj.
(City or Towrf)
GJIjr QInmmmiuipaltlj nf MasHarliUHfttH
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
STANDARD
CERTIFICATE OF DEATH Registered No w.
((If death occurred in a hospital or institution,
2 FULL
r.t • .1 n ~ _ • . tt „ • o_ « q Hit aeatn occurrea in a nospitai or institution.
No Win.thr.Q.p ,Q.OITjJIIUn.l.ty.....h..QS.pX.t.al St. 1 give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
name Nathan H,. Feldman
(First Name) (Middle Name) (Last Name) (if
(If deceased is a married, widowed or divorced woman, give also maiden name.)
so specify WAR)
No
(a) Residence. No ..Campbell* Avenue st. ..Revere.,, . AJass.-. ....
(Usual place of abode) A I If nnnrp^irlpnt piv'#» ritv nr town and !
months. 2.B. days,
Length of stay: In place of death years..
(If nonresident, give city or town and State)
In place of residence .1.6 years months days.
MEDICAL CERTIFICATE OF DEATH
DEATH*™ /.SA.2rr...
(Month) (Day! (Year)
4 I H EREBY CERTIFY. That I attended deceased from
CF.'GL.bi kfLT.k., i9j5T<S.., to 19
I last saw hJ.M,alivp on death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
J&tftrln
Due To
(b)
INTERVAL
BETWEEN
ONSET AND
DEATH
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis
A's
a /-
of deceased? UO.
5 Was disease or injury in any way related to occupation
If so, specify
(Si,
!Wspecll^.h? fl-: i
iigped) ..(JWvA M. I)
(Lli.A. fc.L..£.s.
(PRINT OR TYPE SIGNATURE) ,
(Address) }fler./.A/^Jt/....^A.^..MASS.T>ate..^../..LS'/^ 19. C?..Xr
Xlhevra Tillum of Boston Everett
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
18. 1962
7 NAME OF
FUNERAL DIRECTOR
,.E,aul....E... Le.v.in.e..
ADDREssh.7.0 aarvard.St^., Brookline
Received and filed
/&....> 19..L.U. a™/
ZJMadau.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED r a • ^
widowed harried
or DIVORCED
10a If married, widowed, or divorced n . .
husband of Evelyn gOok...
(Give maiden name of wife in full)
(or) WIFE of '
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE
48
.Years Months Days
If under 24 hours
Hours Minutes
13 Occupation: Pr o..pr i e t or
(Kind of work done during most of working life)
14 o^Biisiness : Hardware 6t.ppe.
15 Social Security No Q34-l.C-644.li:
16 BIRTHPLACE (City) L£.QILi.D.S.t.£.r...
(State or country) 1^ i, S * '»
17 NAME OF
FATHER
Morris Feldman
18 BIRTHPLACE OF
FATHER (City) B.U.3..S.i..4...
(State or country)
19 MAIDEN NAME
OF MOTHER
Ida Finkel
20 BIRTHPLACE OF
MOTHER (City) .B.U.S..S.1.9...
(State or country)
21 informant Kxs* Eve lmJFe ldman
(Address) Ba...rTyoTl .ve. 1 severe
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filejl with me BEFORE the burial or transit permit was issued:
. . ffrc.L.J^r.iyr. ....
(Signature of Agent c
&
(Official Designa
i#i0n)
of Board of Health^>r j)ther)
(Date of Issue of Permit)
i
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.
' ‘ -- L 0
M R-301A
It AUCTIONS
FOR
UL CERTIFICATE
|i giving
S OF DEATH
• not enter
• : than one
■ e for each
a (b) and (c)
’oes not mean
,/e of dying,
I heart failure,
>■! etc. It means
(lire, or compli- .
il which caused
1
id ons, if any,
ifiga ve rise to
’■! cause (a),
h the under-
>1 cause last.
I itions contrib- .
death but not
the terminal
mdition given
ot - Chapter 137,
S19S4. requires
ans to print or
«he cause or
a of death on
:h :rtificates, and
Pt 48, Acts of
'Inquires Physi-
>• print or type
i* ider signature.
.o.
644-928 145
■
4
Suffolk
(County)
GIff? (Unmmnmuralllj of UlaBBarljuflrttB
u, .Wlnthr.D.p.
U (City or Town)
Winthrop CQnuminity Hospital
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
JWl
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
i
Registered No.
No.
St
f (If death occurred in a hospital or institution,
. ( give its NAME instead of street and number)
2 FULL NAME
Lulu Belle Nott
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
[(Was deceased a TvTO
. ( L". S. War Veteran. IN U #
[if so specify WAR)
(a, Residence. No.3Q Pleasant Park Road
(Usual place of abode)
..St.
Length of stay: In place of death years..
(If nonresident, give city or town and State)
months.1.4: ..days. In place of residence 73 years months days.
MEDICAL CERTIFICATE OF DEATH
3 dea?hof. Febi'uary 18 1962
(Month) (Day) (Year)
4 I^H EREBY CERTIFY, That I attended deceased from
19./*..., to 19.**
I last saw h4*Valive on AtT/SA , \l6..fr.. death is said to
f . , .*• fP
have occurred on the date stated above, at /.nr.. ....el.. m.
Female
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Ac. art;
(bT /a to-r/c Z> /a
Due To
(c)
/ieujrcT c/Jyoc/) //t/sue e/oc/vcj '
Af '/b*. /rrosfA/! </ '
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? /vZ>
What test confirmed diagnosis? .£.<..Qr..~. X/z*-/
INTERVAL
BETWEEN
ONSET AND
DEATH
JAMAIS
/u/e&c
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
/<?
(Signed) ... 7S,
or*/
U v
M. D
(Address)
CAe.ac.y fro//
(PRINT OR TWE SIGNATURE)
. Date.. 19. 4.4?.
f \ 1 IVX1N 1 WIN X FTD O
6 .... Wint.hr op.. ...Cemetery., Winthrop, M
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
__ ->L9.6Z 19
(_y.lt Ay IphltaiJf
address 1.7.4 Winthrop. .S.t... Win.thr.Q.p.»M
Received and filed FEfaf.l.iU962
,.19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(writp the word)
Widowed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .Charles. Eugene Nott
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGe7.3... .Years. ..5 Months. .4- Days
If under 24 hours
Hours Minutes
13 occupationr.e.t.ir.e.d Telephone .Operator.
(Kind of work done during most of working life)
M o^BusTness: N. E.Tel .. & Tel C.O ....
15 Social Security No. Oil -05. -05.10
16 BIRTHPLACE (City) ■
(State or country)
3S
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) .
(State or country)
George Dyer
Maine
19 MAIDEN NAME
OF MOTHER
Isabel Webster
20 BIRTHPLACE OF
• MOTHER (City) ... Wl.Jlt h.r.Q.P
(State or country) Massachusetts
Informant Mrs. Omar. !..• Johnson
(Address) 50 PI e as ant ,.Parb Boari .Winthoi
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE The- burial or transit permit was issued:
a£.su
((Signature of Agent of Board of Health or othef/ '
L
(Official Designation)
(Date of Issue (
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
H.E.C.EJ.V.
u-0
FEB 201962 AN
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.
IM R-301A
928145
Qlljr (£mmjumui?altfj of fHaaaarljUHFtta
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
VtJ
IKRUCTIONS
FOR
IL CERTIFICATE
In giving
S OF DEATH
A not enter
u - than one
ai ; for each
1 (b) and (c)
is 'oes not mean
n le o f dying,
A heart failure,
«elc. It means
lie, or compli-
is which caused
•id »bj, if any, 1
i cigave rise to I
vi) cause (a), r
llj the under- l
ng cause last. )
„J itions contrib- .
tcieath but not
the terminal
fndition given
ot • Chapter 137,
Jp 1954. requires
I ans to print or
el he cause or
se: of death on
th rtificates, and
Rt 48, Acts of
>1 quires Physi-
i* print or type
>e der signature.
^.Suffolk
1® (County)
)°Wlnthr.Q.p
fu (City or Town)
\s3 no. ...Winthrop ConviLle scent Home
PHYSICIAN — IMPORTANT
2 full name . Ada Blanche. Wrights on. ( U. S. War Veteran, T\TO
(First Name) (Middle Name) (Last Name) (if so specify WAR) JNU,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
((If death occurred in a hospital or institution,
St. | give its NAME instead of street and number)
(a) Residence. No. 11 Nahant Avenue
(Usual place of abode)
..St.
(If nonresident, give city or town and State)
Length of stay: In place of death. 4 years months days. In place of residence 40 ..years months days.
MEDICAL CERTIFICATE OF DEATH
3 DEATHOF.....l’.e 18 19.62
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, That I attended deceased from
Jan. .13, 19. 62.., to Feb* 18... 19....62
I last saw her “live on Feb.* 18, ...., 19....D.2, death is said to
have occurred on the date stated above, at ilQ....p*. ..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Arteriosclerotic & hypertensive
heart disease :
Due To
<b). Generali zed arteriosclerosis
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
5 yrs
Z.jrs
Was autopsy performed? P.P.
What test confirmed diagnosisCllnicH ...<Sc...labQra.tOry.
5 Was disease or injury in any way related to occupation of deceased? J30...
If so, specify ...
)
(Signed) ..I.W — \ Zc^~. /T.'f >TT. M. D
M. .Trauns.te.in, . iLJu
13 20, ,» 62
6 Winthrop Cemetery.,. Winthrop, Mas
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
February. 20,1962
.19 _,....
7 NAME OF
FUNERAL DIRECTOR
ADDRESS 174 Winthrop St.,. Winthrop,
FEiiIii.M2;
Received and filed
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (quite the word)
married Married.
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Sydney John Wrights on
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
age8.3... ..Y ears...7 Months.. 16 ..Days
If under 24 hours
Hours Minutes
13 ocscupationr.e.t.lr.e.d....Fur.....S.eamstr.es.a
(Kind of work done during most of working life)
or Business: .... retail Dept. Store
15 Social Security No. 032-20-0.Q65
16 BIRTHPLACE (City) ...
(State or country)
London
England.
17 NAME OF
FATHER
Arthur Smith
18 BIRTHPLACE OF
FATHER (City) L.On.d.O.n
(State or country) England
19 MAIDEN NAME
OF MOTHER Mjmj ^TI) Smi t.Vl
20 BIRTHPLACE OF
MOTHER (City) L.Q.n.&.Q.JOt
(State or country) England
Informant
(Address)
Reginald J. .....Wrights on
11 KanantTAvenue , TTiri t IlropL
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the/burial or transit permit was issued:
'5.USS • L C. ,r
(Signature of Agent of Board of Health or other) . -/
/A
(Official Designation) (Date of Issue of Pe
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERyjQE 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.
\f R-301A
I RUCTIONS
I F0R
It. CERTIFICATE
I giving
S OF DEATH
■not enter
■ than one
I; for each
a (b) and (c)
m'oes not mean
lie of dying,
a heart failure,
:ii etc. It means
■ re, or compli- p
il which caused
dims, if any,
'Igave rise to
jet cause (a),
in. the under-
jg cause last.
otitions contrib- .
fpeath but not
the terminal
_ ndilion given
■{Chapter 137,
if 554, requires
ci s to print or
t cause or
•i death on
c tificates, and
t«i48, Acts of
rcuires Physi-
torint or type
ui tr signature.
59-92 5686
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
Ov./ CThr Cmntmimupallli of USaflHadiUBrttB
\oAo
(County) i /W a\ Hi K
.W & STANDARD
/ xt f .......... CERTIFICATE OF DEATH
(C.ty or Town) ^ ^ / O *t rt 16- A- AJ * /f, S£, ^
No. M d (/ M o c & AT /•/ d aa c St. I give its NAME instead of street and number)
To be filed for burial permit
with Board of Health
or its Agent.
' a
Registered No mt.'.Tst..
(If death occurred in a hospital or institution,
2 FULL NAME//1 A Ar./.O. Si L.r./.M <f t& y\../t-'7j T H <?. /A f9 A
(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)
ta) ReMdence. No. /.jLtr.. i— .4lfc i &e. /ft. W... C • C (At. £ 4f. f.. £ A ..St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months ...c5a days In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
.Ek..b. is , [St
(Month) (Day) (Year)
4 1 HEREBY CERTIFY,
19 to
I last saw h alive on
have occurred on the date stated above, at
That I attended deceased from
19
, 19 , death is said to
m.
8 SEX
9 COLOR
is /■+ / r u
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Dpqfrlt a y pa y eh ^ ct*?' fe’T? a
INTERVAL
BETWEEN
ONSET AND
DEATH
i ihe
4* fto>'o Vi a ym $ / m. s i o h ^ d ^ .
i iTTT~ ( d V ■p-y-r-—- . ^
hi e II
Me Todil?A S€L, tfl
1^- y' C LL Tg ,5 i h i -C i (Ldg, T' d ffS c^Lc - LtXiXL4_
OTHER CL / — l . i I 7 ,
SIGNIFICANT
CONDITIONS
5 1 Q 1. i J- » CL il n. r C (■ I c cij,
-4^ ~t(
Was autopsy performed?
W'hat test confirmed dial
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
or PIVORCE1 1/3 / y-a **CtLo
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of A. £Au£ XMfn A jeK
(Husband’s name in full)
I 11 IF STILLBORN, enter that fact here.
I-
12
AGE £..Ck..\ ears Months Days
If under 24 hours
Hours Minutes
sfsT T7. JL/...X .4 -V...
S Was disease or injury in any way related to occupation of deceased?
If so, specify .a _ C. /..J.
(mini UK 1IIX 3IUINA1U
Ss)^L:,.....VL^rkVV..d|^r.^.4.^Dat
'.d.ja..A.A..ar:.hl 1 £
6 w a .
Place of Burial or Cremation
DATE OF BURIAL SdAJUjL
7 NAME OF ,0
FUNERAL DIRECTO
ADDRESS^ J fcOrty
Received and filed '
(City or Town)
\^2~
13 Usual ^ n lr‘
Occupation: Cr frr.iZ. rtf/s ; ;
(Kind of work done during most of working life)
14 o^BusTness y./>fT.MAhl AA'r'dM .£
15 Social Security No/ 4 ^ .4 d 0.
16 BIRTHPLACE (City) O £ HT af Ar. ..
(State or country) /yg. A, tf 4
17 NAME OF
FATHER
18 BIRTHPLACE OF /-
FATHER (City)
(State or country) ^ A-d’J"
19 MAIDEN NAME __
OF MOTHER A JlA F L J A &. 6, j£f i. / £■
20 BIRTHPLACE OF
MOTHER (City) .. /'../..c.r.. d..d...
(State or country) A/- S -
Informant uaAM
(a\ddress) y ^ C 6- ?}- A* K ^ iZ C H i g * 4 /T A_
fte 19 1962
(Registrar)
I HERF.BA CERTIFY that a satisfactory standard certificate of death
war Tl6d with me BEFORE the burial or transit permit was issued:
... . u'.i
/ I (Signature of A^enf of Board of Health or-otnen
,r\ai- .i r\- a; — \ (Date of Issue of Fermip /
\
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVIC&^ii'^'.,
DATE OF DISCHARGE
RANK, RATING i.bll
ORGANIZATION AND OUTFIT
SERVICE NUMBER
FtB19i952ffi
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.
A R-301A
ST
• RUCTIONS
FOR
C CERTIFICATE
I giving
OF DEATH
Ic iot enter
than one
for each
(b) and (c)
oes not mean
t oj dying,
heart failure,
I etc. It means
f‘, or compli- ^
hich caused
mtions contrib- .
'■Olealh but not
■ the terminal
midition given
te Chapter 137,
01954, requires
ic ns to print or
■ e cause or
:l death on
lftificates. and
t* 48, Acts of
liuires Physi-
> t print or type
i Bier signature.
if 928145
Suffolk
IQ
(County)
GIljp (£mnmiinuipalth nf iHaBBarljUHrttc
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.
binthrop
iU (City or Town)
-inf] hr»nr> rnmroleconf ilnno f(B death occurred in a hospital or institution,
a. No. St. \ give its NAME instead of street and number)
r>-
Registered No r.....
PHYSICIAN — IMPORTANT
2 FULL NAME Willi^. G...M.C.Q.X J u' S. W^rTeU*
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
-^—112 Pleasant Street
(a) Residence. No St
IS
eteran,
so specify WAR)
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death years 2 months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF h,
DEATH I.
(Month)
0
"(Day)
2- ,
(Y ear)
4 I
.HEREBY CERTIFY, That I attended deceased fror
r2)..£...GLrr. , 19 to...v I9..k?
I last saw hLil^live on h iz , 19...^..iferTdeath is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a
) A..C.Y QyiJc.r.'l
Due
(b)
V /'<£, Y i'o S € 1 of- 1’ Cr b.
Due To
(c)
0THER . _
SIGNIFICANT if.D..
CONDITIONS
Was autopsy performed? A/e
What test confirmed diagnosis^?.. l-Lw
INTERVAL
BETWEEN
ONSET AND
, DEATH
/l- hid r
£±
5 Was disease or injury in any way related to occupation of deceased?
If so, specify y
W:
y...
(Si|
m aPitLCl,, M. D
LBS
(PRINT OR TAPE SIGNATURE) ,
(Address) 7 Ac'.lr h ..ff up,. MA SS . Date.. /^.o7...i9^ ^ i]
6 .WQQ.dl.awn Everett
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Feb. 23
.19
62
7 name of Howard S Reynolds
FUNERAL DIRECTOR .«
ADDRESS
'.Vinthrop, lass
Received and filed
ffcb 2 1 1362
.19..
(Registrar)^.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Llale
9 COLOR
white
10 SINGLE (write the word)
MARRIED
widowed Larri
or DIVORCED
10a If married, widowed, or divorced „ r> j
husband of .^sanGard
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
.12
AGE....r.Q Years....? Months...- Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : Elec trican
(Kind of work done during most of working life)
14 Stee..: Contractor..
15 Social Security No Q.l.Qr..Ql“l.d9Q..
16 BIRTHPLACE (City) ....
(State or country) GCOtuand
17 NAME OF
FATHER
James Nicol
18 BIRTHPLACE OF
FATHER (City) — ....
(State or country) Scotland
19 MAIDEN NAME
of mother Uanuilla Colled ge
20 BIRTHPLACE OF
MOTHER (City) „
(State or country)
Scotland
Informant
(Address)
Kanuilla Iloore
I.'orth Readier;, lass,
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
'^C^£tLAc:L
(Signature of Agent of Board of Health or other)
......T
(Official Designation) (Date of Issue of Permit)
CV-e ) /i?K
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
received
FEB 2 11962 <
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.
/ 1 R-301A
(RUCTIONS
FOR
| CERTIFICATE
giving
|OF DEATH
ot enter
than one
for each
(b) and (c)
pel not mean
of dying,
heart jailure,
€tc. It means
e, or compli-
“b hich caused
/ions contrib- .
j’eath but not
i the terminal
iition given
ce Chapter 137,
0 1954, requires
i< ns to print or
1>l e cause or
pf death on
Irtificates, and
I 48, Acts of
ijuires Physi-
■ t print or type
• » ler signature.
o
t
/
>28145
(Snmmmiumtltlj nf H0aHHarI|UHPlta
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.
« S.uff.Qlk
“ (County)
° Wint.hr op.
U (City or Town)
i no Win.thr.Q.p......C.Qmrauni.t.y H.o.s.p.it.al .... St. j give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
deceased a
Registered No.
3S
2 full name Julius Lank j U. S. War Veteran, A J
(if so specify WAR) . Fvf
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. .1.1 Pearl Avenue st
(Usual place of abode)
.1
Length of stay: In place of death years.
months..
days. In place of residence..
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
•Bh ’
(Month)
X X
(Day)
(Year)
4 1 HEREBY CERTIF Y ., .
19.5.Q...... to JEkM* X.Xnr. , 19.6..2*
I last saw h.i^.alive on .... ..., 19.J^..2rrrr, death is said to
have occurred on the date stated above, at
That I attended deceased from
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due
(b)
I
1
Due To • . ,
(c) A>/~e3'0 Sdle Y0 5 fs
OTHER
SIGNIFICANT
CONDITIONS
nt $ s i.du.t j. <rf.. . . . d.e re fc> >.<£./.
WaY If itac/g
Ws
INTERVAL
BETWEEN
ONSET AND
^gyvs.
YS.
JiYS.
Was autopsy performed? f/r... s?.
What test confirmed diagnosis? .'..(L^fc./..
1
5 Was disease or injury in any way related to occupation of deceased? Mo
If so, specify
(Sigi
gryed) , L^.. M. D
ULHAMcS U&&..R.MAM
. (PRINT OR TYPE SIGNATURE)/ .
(Address) Pat e.Jfc/3.>/ 1961.2..
Myi M i 3
y -
...U'tAXMt..
(City or Town)
DATE OF BURIAL 19!
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
/,/uA±.4L..e::....
Received and filed
FEB 23 1962
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 S1NOLE- (write the word)
MARRIED
widowed i‘ia r r 1 ea
^WVttSFED
10a If married, widowed, or divorced .» >,1 /.)
HUSBAND of :
(Give maideb'name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 *w —
AGI&/...../...Years Months..
...Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
id.
(Kind of work done during most of working life)
14 Industry CO -
or Business: ..b-j.
15 Social Security No. — 3 ■ ■
16 BIRTHPLACE (City)
(State or country)
atui
* xmzz"
17 FATHER*" /S&Aju tf-
18 BIRTHPLACE OF
FATHER (City) ....
(State or country)
19 MAIDEN NAME
OF MOTHER
/(Si <.<; (t
20 BIRTHPLACE OF , 1
MOTHER (City) Jkk-.tAdA.a^..
(State or country)
// // d c. * / >2 1 /l
Informant
(Address) /*/
=3
I HEREBY CERTIFY that * satisfactory standard tertificate of death
was filed with me BEFORE the burial or transit permit was issued:
(/. L . .(L. . . . i .
_ _
(Signature of Agent of Board of H earl t^ or other) , ,
ft
(Official Designation) v (Date of Issue of Permits
2
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY-ySERVICE.
DATE OF DISCHARGE
RANK, RATING
./■/ K'Ki
ORGANIZATION AND OUlTiT^.V.'..-...^1^.p..
SER VI CE NUMBER
[HR OP.
s\>
FEB 2 31962 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 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-303
ft. *) '
os SO
|ou
1<
i£2 r
r *«• 5
Qu '
cr
g — «*«
f; '</> 600
|< 2 -
| (0 vo
| 5*JU ^
|r- *
D A «
ex
*1 3 .2 u
■' «
r«£K
— M rss>
*1 2
13 V .
|OX«
*1 c *a ro
Z
|i,‘-
/
SUFFOLK
(County)
WINTHHOP
(City or Town)
®l )e Commontotaltf) of 4Hag0acf)USetH(
KEVIN H. WHITE
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.
*> 7
O OO Vof oTOnq Ronrl ((If death occurred in a hospital or institution,
No .^™.5?..C7. St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
^ FT’T I VAMF ijAJVlU JliJj lM.CiSi3iiiJLj I iTi ((Was deceased a
( FirsV Name) (Miipe Name) (Last Name) S' War Vetera
SAMUEL. NESSELLE
(Fii
(If deceased is a married, widowed or divorced woman, give also maiden name.)
/eteran,
so specify WAR) r...
(a» Residence. No. 30 Cutler Street st. Winthrop., Massachusett.s.
(Usual place of abode) (If nonresident, give city or town and State)
..years months days. In place of residence 2.3years months days.
Length of stay: In place of death..
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 date of February 22, 1962
(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.)
9 SEX
Male
10 COLOR
White
11 CITIZEN
OF U.S.
YES NOD
12 SINGLE
D 'JQ-
MARRIED
WIDOWED □
DIVORCED —
UNKNOWN
GQfiOMMY-AKWRr biseflSe
HUSBAND
(Give maiden name of wife in full)
(or) WIFE of
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19.
■t Emu-lo..y.ed..
Q-10~G-5~7:
While at work? Was a
6 Was disease or injury in any way rel
If so, specify
(Signed)
(Address)
Leonard
25 ShfMu
7 Beth o' oaeph #3 , Woburn
(Husband’s name in full)
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, or1
public place?
(Specify type of place)
Manner of
Injury
(How did injury occur?)
Nature of
Injury
ork done during most of working life)
BieTOTi", Maw,
NAME OF _ . , .. _
father David Neeselle
20 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
21 MAIDEN NAME
of mother Gertrude Medson
22 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
Russia
Place of Burial, or Cremation.
DATE OF BURIAL ...f 2.3 p
(City or Town)
..19
62
23 inform™, Anne Neseelle
(Address) 30 •Cut,Xch'""Bt» WinthTop"
8 funeral director ....P..®.P.J.3.ffli.B Blrnbach
ADDRESS
10 Waahlngtan St. parch...
Received and filed
A TRUE COPY ATTEST:
FEB 2 3 1962 «...
(Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was'Tiled with me BEFORE the burial transit permit was issued:
/ (Signature of Agent of Board of Health or other) J /
/\ ^ . v - n s') / r> / / ^
(Official Designation)
(Date of Issue of Permit)
m
id
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
S £ C £ ; V £ D
RANK, RATING
TV'
ORGANIZATION AND OUTFIT
V.;
SERVICE NUMBER $
£19! t'-Y
>*7
'A.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance' of the following Tules of practice:
(1) Attending physiciansptfll Qeftif^^o/^ch deaths only as those of persons to whom they have given bedside
care during a last illness from disease %ifreTat'ed 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.)”
II R-301A
h'
t RUCTIONS
FOR
Si CERTIFICATE
1 giving
3) OF DEATH
10 ot enter
3i than one
u for each
a) (b) and (c)
r| >et not mean
to / dying,
eart failure,
tc. It means
, or compli- -p.
rip hich caused
Mms, if any,
ave rise to
\cause (a),
the under-
ause last.
--lions contrib- _
tu'eath but not
! I the terminal
! Wndition given
Jt* Chapter 137,
> 1 1954. requires
sic ns to print or
le cause or
■ etof death on
nortificates, and
pt« 48, Acts of
. Inuires Physi-
s t print or type
e l ier signature.
i-49.
28145
1
2 Suffolk M
(County)
(ttnmmmtuiraltlf nf MaaaarljUHrttB
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.
iu Wint.hr.o.p..
[U (City or Town)
'2 Wn Wlnthrop Community Hospital _ sc|?4tJ«!fSSl^^^n^Sl3!»
PHYSTCIAN — IMPORTANT
Female Basrner’a rcwas deceased a
2 FULL NAME ..F' .r.Z. ... ° \ U. S. War Veteran, ^
(First Name) (Middle Name) (Last Name) (if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 160 ...Webs ter ... 3 1 st.
(Usual place of abode)
..East Boston
(If nonresident, give city or town and State)
Length of stay. In place of death years months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 deathjf. February 24.., 1.9.62
(Month) (Day) (Year)
4 I H E R E B Y C EJi T I F Y , That I attended deceased from
Feb 2.4 to Feb... 2.4 19.6.2.
I last saw h...S.Hive on e.b... 2.4. ., 19.....6.2, death is said to
>..:..5.QA.m.
have occurred on the date stated above, at ...
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Prematurity
Due To
-(b) Premature separation of
Due To
(c)
Placenta
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? . No
What test confirmed diagnosis? N 0He...
INTERVAL
BETWEEN
ONSET AND
DEATH
12
AGF.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
3 • yjkfviA**
(Signed)
M. D
(Address)
1 iiir.'K ® vvv* s S i-A-Fift/ie ^
(PRINT OK TYPE SIGNATURE)
J/ \L ..Date./Jk# ZY .19.6-?
Holy Cejtt&te/uf Maiden
Place of Burial or Cremation (City or Town)
9eb0 27, 62
DATE OF BURIAL * 19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
U-inc,ent Kapino
9 CkeLi-ea 44 , (.gaX. &o 4<ton} Mgaa..
Received and filed
19 ..L'.'.L
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEXt
9 COLOR
tuhiZe,
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
vi i it me rvuiu
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.
If under 24 hours
rjT. Hours., rr. Minutes
13 Usual
Occupation:
mnz.
(Kind of work done during most of working life)
14 Industry
or Business:
none.
15 Social Security No.
none.
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
£ dtvcutcL Eax^neAJX
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
(jJinthnop, /V4&&,
19 MAIDEN NAME
OF MOTHER
Mo/UfGA,et bdJSooao
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
'7 fo4Zon£ttaA&.
[cLvgaxL l^ci^neAja ( f ath&t)
Informant
(Address) J£Q dl t,. f f.ISQAeCO^
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
T
SREBY CERTIFY that a satisfactory stand
Sled with me BEFORE, the burial or transit
(Signature of Agent of Board of Hdalth oi
or other)
(Official Designation) (Date of Issue of Permit)
/ V
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ED
RULES OF PRACTICE FEB 271962'*
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.
1 R-301 A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
for each
(b) and (c)
>es not mean
oj dying,
heart failure,
etc. It means
le, or compli- ^
■thick caused
ms, if any,
ave rise to
tause (a),
the under-
ause last.
--'■ions contrib-
toleath but not
1 i the terminal
Wndition given
ff
Chapter 137,
j!954, requires
si* ns to print or
le cause or
el)f death on
h* tificates, and
Pt# 48, Acts of
, Ijuires Physi-
s t print or type
efcler signature.
>4.
2814S
/
(Enmmmuuraltlj nf UEaHHarfyuarttH
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.
jjS A/
2 Suffolk 'AA
Q (County) ^ A
° Winthro.p \/'z
U (City or Town)
j T|T-i n4-Viv,^_ n. •. . ▼ . .. I death occurred in a hospital or institution,
a. No. ™.i.“.X!.nX!.Q.p. L.0imn.unit.y ■H-O'S-p-ifesl St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
Registered No.
2 FULL NAME
L&&
(First Name) (Middle Name) (Last
(If deceased is a married, widowed or divorced woman, give also maiden name.)
f . » . PttYMUAN llYlrUK 1 A IN
Green (ZinM'f't dw~*v« A 4
Last Name) 1 T'f so specify WAR) /..“..O'.
(a) Residence. No. .8.8. Crescent Ave
(Usual place of abode)
22days. In place of residence
Length of stay: In place of death years months.
£
Revere
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
3 death3 Ze.hr.uary. 24., ... 1.9.62
(Month) (Day) 7 (Year)
4 I ,Ai ER/EBY CEKTIF Y^ That I attended deceased from
5b 19...l?.d£ to (&.#. 19<Ci3..
I last saw h.OfCalive on .... £....y , 19. death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Ca r t / /o o t'rt <k y / S
Due los
<b) Q
a rc i In o
Due To
(c)
n
fLov
it a /e rai )
a y
A
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? ....No
What test confirmed diagnosis?
INTERVAL
BETWEEN
ONSET AND
DEATH ,
5 Was disease or injury in any way related to occupation of deceased? 73 a.
If so, speci
M. D
(Signed)
(Address)
„ s , (PRINT OR.TYPeWGNATURE), / r
/ A sj f W'jE. JO... ^4Date ,L./shA. . . 1 9f ?...3>.
J
6 £..IC£j-'.£L'
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
fi./. aL.^Ct. 19.^..*?
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
MAR 5 -19.62
.19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
10a If married, widowed, or divorced
HUSBAND of
■ (Give, maiden, name of wife in full)
(or) WIFE of C^. Q..X...d<.&.fy.
(Husband's name in full)
TDOWED .
DIVORCED/ vj(0 ) f , fj /f
11 IF STILLBORN, enter that fact here.
AGE^.^/Years <f... .. Months.. .../Z Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: 1
:V._L.) 1 , :.
(Kind of work done during most of working life)
14 Industry >
or Business: .t:nsr£i7...C)h...^m..
15 Social Security No.
16 BIRTHPLACE (City) .
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
- ^
19 MAIDEN NAME
OF MOTHER
7
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
21
Informant
(Address) fVV
QA.Iy.1zj.. Z)...a±y. „....,
Yf L‘ J c V >1 -j /Tve-<e-, ■; /r r
fVrt -d-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me I^EFORE the burial or transit permit was issued:
j (Signature of Agent of Board of Health or ofter)^,
7/mAU-. ....£/.
(Official Designation) (Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
DATE OF DISCHARGE
RULES OF PRACTICE
MAR -51962 AM
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.
DRM R-302
V
[a Suffolk
|Q (County)
. (Commnmaraltl) nf HlaHHadjUHPtta
JOSEPH D. WARD ReVPrP
Secretary of the Commonwealth a^y...*.h*-P
DIVISION OF VITAL STATISTICS (C.ty or Town making this return)
..Revere
(City or Town)
COPY
CERTIFICATE
OF
OF
No...
DEATH
Grover Manor Hosoital *
Registered No.
30-
( ( If death occurred in a hospital or institution.
( give its NAME instead of street and number)
full name Margar at ...Place a (Buckley )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
.. ) ( Was deceased a
|U. S. War Veteran. \r
\if so specify WAR,... Jj..Q..
-
(a)
Residence. No... 21 Nevada st Winthrop, Mass .
(Usual place of abode) (If nonresident, give city or town and State)
6 years. ..3-fnonths.2il.days. In place of residence6..Q..
Length of stay: In place of deatO years.. ..JL.months.
..years. months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
dea?h°F February 2k, 1962.
(Month) (Day) (Year)
4 I HEREBY CERTIFY. That I attended deceased fron
Nov* 1 19..&&. to Feb.* 2k 19 .62
I last saw h...£&Ne on Feb* 2k 1962 death is said to|
8 SEX
9 COLOR
10
Female
White
have occurred on the date stated above, at IXSjQAn
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a> ...Uremia
<bT ToMyocardi t is
Due To
(c)
..Chronic N ephritia
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
JLE (write the word)
MARRIED .... ,
widowed w I a owed
or DIVORCED
3days
6mo.
2yrs«
W
Was autopsy performed? .t.t. .
What test confirmed diagnosis? yAVBf y ° *
No-
'S Was disease or injury in any way related to occupation of deceased ?
If so. specify
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of Joseph Rlacco
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
(Signed) ...J.am.e.a .F.* Bums.™
(Address, ^Verett Date... .2/25/.
.19
M. D
6?
6 Winthrop Cemetery Winthrop
Place of Burial or Cremation (City or Town)
date of burial February 27 J» ly 62
funeral director Arthur J. C,Kaley
ADDRESS ..
Reeei ved and filed ”
( Registrar of City or Town where deceased resided )
AGE
87
Years Months Days
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)
Ireland
17 NAME OF ,, , , , . ,
father Michael Buckley
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Ireland
19 MAIDEN NAME
of mother Ellen Sweeney
20 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Ireland
21
Informant
(Address)
Hjlen Wyke
evaua St. , Winthrop
J
<~\S>
If under 24 hours
Hours Minutes
A TRUE COPY U
ATTEST:
( Registrar of City or Town where death occurred )
— 62
date FiLfD February 26 ,
..19..
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
[] R-301A
CTIOriS
DR
ERTIFICATE
iving
F DEATH
enter
an one
or each
) and (c)
not mean
ol dying,
art failure,
, It means
or compli-
ich caused
if any,
rise to
use
i
<?■■
'Mf ai ^aacarliuHft^UT - OF TOWN
JOSZ?:-; D. WARD
C'CRETARY OF THE COf.'?.:ONWEALTH To be filed for burial permit
DiVISIO.Si OF VITAL STATISTICS with Board of Health 04
or its Agent.
STANDARD
CE3TIF2CATE OF DEATH
e rtie to 7
use (<j), >
e under - i
ut last. )
eontrib-
(V th but not
he terminal
ition given
r
- 1 hapter 137
154. requires
s to print or
■ cause or
death on
c cates, and
e|8. Acts of
(Wires Physi-
l ’int or type
u |r signature.
f 1 6 1962
2 kv(\S<~
IX 8U5
(County) k
_ , i: \ _ or its Agent.
vV<A-Cf\ Vv STANDARD
(Ci^rTown) V > CERTIFICATE OF DEATH Registered No.
N° ._ St. i(givdeef^ NAMlf instead
PHYSICIAN — IMPORTANT
t\(V . . . a _ \ »
2 KI LL NAME
, - ’ — — *»*• i ns unsii, insicau 01 street ana numoc
t» . s PHYSICIAN — IMPORT!
L :...Z WaXlemn. s /
n/J,rSl • . j (Middle (Last Name) {if so specify WAR)
Ui deceased is a married, widowed or divorced woman, give also maiden name.)
. No. Sb., h<M^x$\Q.
(a) Residence. _
(L'sual place of abode)
..Sr.
V0u%m\Op
(If nonresident, giveYity or town and State)
Length of slay. In place of death years months. 'Vv.. .da; In place of residence. ..i^~ ..years months days.
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
r~
(Month)
(Day)
(a eA
(Year)
* 1 CERTIFY, That I attended deceased from
19 k^„, to.— L|..^ W.ks'k.
I last saw h'wAC.alive on .L..I ..^ — .^9.fp. , death is said to
have occurred on the date stated above, at |. ,d?d. i m. I
8 SEX
9 COLOR
PcMFf.) r.
U/h ?Tc~
DEATH WAS CAUSED BY: IMMEDIATE C. jSS
* BETWEEN
| c:::rr ;.::a
(a)
Due To
vb)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED re ,
WIDOWED 'zl/cr /r
or DIVORCED '
HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
(Husband's name in full)
II IF STILLBORN, enter that fact here.
12
AGE..CNL...Y ears... .LL... Months...,
Days
If under 24 hours
Hours Minutes
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? KMD..
What test confirmed diagnosis?
S Was disease or injury in any way related to occupation of deceased?
If so, specif
(Signed)
LAoSESt^tX..
(PRINT OR TYPE: SIGNATURE)
... M. D
(Address) ■^5.qA tfP b ."A VX^jf^Sjate )..\Q(, 19^sJ
~ J — ^>u3jY(3#\:
deM, 2.&ZR&7AC...
Place of Bunal or Cremation (Citv or Tnwnl
or Cremation (City or Town)
DATE OF BURIAL £?73. N/. Uj 1 9 .4 .S,
(Kind ol ,,
MSteL.,i2ei^iy tftr/ * Cr/i/h-
! 13 Usual ey u
Occupation :
(Kind of work clone during most of working lile)
15 Social Security No
16 BIRTHPLACE (City) ...... J3..£..'C7..
(State or country)
17 NAME OF . .
— Lqi,r.\£
18 BIRTHPLACE OF rp ,
FATHER (City)
(State or country)
19 MAIDEN NAME
of. mother Lett# B £>
20 BIRTHPLACE OF 4
MOTHER (City) fS.R'.'f
(State or country)
7 FUNERAL DIRECTOR ./A/ReMoAD... !t> if
ADDRESS
$Reejd}}l<z..
^iv^and
a-r..:. . . ff. \ Li. a^rv\ 'a.
19
(Registrar)
Informant'
(Address)
No&ds- _ r
^ .P u.~ ULAttLlRd-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was/.-.^y with mp^BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
// -i-
g
(Official Designation)
/
(Date of Issue of Permit)
Y I/, !3s ]}
%TJfm ^0by- ATTESTi
Re^istrnr
':-3
CERTIFICATE OF DEATH
STATE OF MAINE DEPARTMENT OF HEALTH AND WELFARE X " "" '
STATE FILE NO.
32
ACE OF
TH AND
j'SUAL
IDENCE
1. PLACE OF DEATH
a. COUNTY
innei
b. CITY, TOWN, OR LOCATION
Gardiner
c LENGTH OF STAY IN lb
45 minutes
d. NAME OF
HOSPITAL
INSTITUTION u
I f noi in hospiloi. *3. yc Street cddre**)
hospital o?^ar diner paoer Mill
2. USUAL RESIDENCE Where deceased lived If institution: residence before admission
STATE
Mass,
b. COUNTY Suffolk
c. CITY, TOWN, OR LOCATION
V.inthrop
d. STREET ADDRESS
55 Cliff Avea
c. IS RESIDENCE ON A FARM?
YES □ NO K
EDENT
SONAL
ATA
PE OR
I NAME
CATH
1= TO
X'jiRNAL
TC.ENCE
lama
3o.NAME OF DECEASED-Firit Narr.o1 3b. Middle Name
La//ava ! To
' 3c. Lait Namo
I
5. SEX
Male
6. COLOR OR RACE
«. hlte
I0o. USUAL OCCUPATION O vc .
iX u 5T? ° 1 L/ 2 " i V c 1 f ■ evcn ,f
7. Worried uC Never Married
Widowed Divorced
1 Ob.
KIND OF BUSINESS OR
INDUSTRY
Miller
8. DATE Or BIRTH
Juno 26, 1907
DATE Month Day
OF Ton 1 1 1
DEATH v ‘ '
Year
9 .AGE (In yeorsNorider I yeor
lait birthdoy) moj Dayi
54
11. BIRTHPLACE (Stole or foreign country)
Hampden, Maine
13. FATHER'S NAME
Leslie B. Miller
14. MOTHER'S MAiDEN NAME
Lou Stella Tayjor
I b WAS DECEASEO EVER IN U S ARMED FORCES?
17. SOC. SECURITY NO.1 18. INFORMANT
003“C5-264G Adele L0
(**1^(5 or Mn*^
(It yes, g.ve wer cr ootes of serv.ee)
If under 2^.hrs
12 CITIZEN OF WHAT
COUNTRY?
15.^"tyAME OF SPOUSE (If .Lorried)
Adele Lurvey ...ilia:
- 196I&'
19. CAUSE OF DEATH (Enter only one cause per line for (o), (b), and (c).)
PART I. DEATH WAS CAUSEO BY:
. IMMEDIATE CAUSE (a) —
1 Xt'”:. Tr; , due tow
obove cause (o)
stating the under-
lying couse lost
\ \ 95 GJ
liff aM-.-.so
tiron* Mas So
N U UC is-/ p—
} \ W\V£
J DUE TOMc)l— V*
• or (o;, [Oj, ona (c j.j , \ •
1 ^ / ■ V-’« ; '' ■ \t
interval between
ONSET AND DEATH
PART II. OTHER s\<
JlTlONS contributing to deoth but not reloted to the terminol diseose condition given in Port I o,
N : '
y
/) A I-
20. WAS AUTOPSY
PERFORMED?
YES NO. •
2 la.
ACCIDENT
n
SUICIDE
□
HOMICIDE
□
21b. DESCRIBE HOW INJURY OCCURRED. (Enter nature of .n,ury ,n Po-I 1 or Port 11 of .tr
m 19.)
21c.
TIME OF
INJURY
Hour Month,
o.m.
p m.
Doy, Yeor
2 1 d. INJURY OCCURRED
'HILE AT NOT V/HILE
'ORK AT WORK. □
2 1 e. PLACE OF INJURY (e g., in or obout home,
form, foctory, street, office bldg , etc.)
2 If. CITY, TOWN, OR LOCATION COUNTY STATE
rs
“IAN'S
DICAL
NER'S
ATION
22a. MEDICAL EXAMINER: I hereby certify thot deoth occurred ot the time
ond from the causes stated above, and thot I held on (investigation) (autopsy)
on ihejemoms of the deceosed os required by low.
23a. SIGNATURE
:TURE \ S’ , (Degree or tit,
Uti, )>, .0 I
title)
Q
22b. PHYSICIAN: I hereby certify thot I attended fh«« cir<eo\*vj If.
to and last saw him olive on
it
m. on the dote ond from the
23b. ADDRESS
'»:ral
Ajor
24a. BURIAL, CREMATION,
REMOVAL /Specify)
Burial
24b. DATE
1/14/62
24c. NAME OF CEMETERY OR CREMATORY
Locust Grove Toomb
25. FUNERAL DIRECTOR ADDRESS
Brookings 1 Smith Bang or, Me
26. DATE RECD. BY LOCAL REG.
° / " // ~fr X
rk ,7
23c. DATE SIGNED
/ v/zil
24d. LOCATION :pwn, or county)
Hampden, Me J
(Stoto)
27
REGISTRAR'S SIGNATURE^
tV 'T'r h : . . >- r
r, X.
/
*
. \
APR -51962 PH
50M-9-59-926111
Suffolk
(County)
Chelsea
* (£nmtmmuiealti| of fMaHHar^uoptla
joseph d. ward Chel3ea
Secretary of the Commonwealth ~ "vv v
(City or Town making tr. -e*urn)
(City or Town)
Chelsea :...MeTOrialm
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
15
33
Registered No.
No..
..St.
1 (If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
) (Was deceased a
jU. S. War Veteran.
\if so specify WAR,
(a, Residence. No IP feS.P©. C t ... AVf / ffifelt hPOp. J Mi*.*
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of deatTT. years..™. - months ?..days. In place of residence.. ..l§ears months flays.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ..
(Month) (Day)
(Year)
4 I HEREBY CERTIFY. That I attended deceased from
Jsn*ll , 19.52... to Jaru.12 19.62.
I last saw 6.3?alive on .... Jan.*12 196.2, death is said to|
have occurred on the date stated above, lQ:05A«r
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Congestive heart failure
?buf T” Myocardial infarction
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed ?
What test confirmed diagnosis " C.l l fll-CO-l
5 Was disease or injury in any way related to occupation of deceased ?
If so. specify
, Signed ,^.^y.^.^.OT®......A..*.^.b.?iCa M. D
( Address
4 ve •Rove ^^1/12/6^,,
~ St .Josephs Cem. ,W.Roxbury
Place of Burial or Cremation^ _ _ _ _ _ (City or Town)
DATE OF BURIAL
Jan°:i5#1962
.19..
NAME OF
FUNERAL
ADDRESS
wiifiCTQi^ichard c .Kirby, Inc.
917 nln gt oh 8 1 .E . Boston
Received and filed MAR 1 3 1SS2 l9-
(Registrar of City or Town where deceased resided)
8 SEX
Femal
e
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED , ,
or DlVORCEftjdOWed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
«or) wife of J°hn J.Dunn
(usband/s
Date of blrt’fi-ifaae^S'Jia&l
11 IF STILLBORN, enter that fact here.
A($>
.Yeai’s 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. none
16 BIRTHPLACE (City) y ‘vvy: •jH''
(State or country) 1P6 XcLIiG.
17 ^tmhee^ John Coughlin
18 BIRTHPLACE OF
FATHER (City)
(State or country
Ireland
19 MAIDEN N
OF MOTHER
Ilallisey
20 BIRTHPLACE OF
mother (City, Ireland
(State or country)
informantMrs»Rlta Cullinane-dau*
(Address) 10 Prospect Aye . «Winlhrop
A TRUE COPY
ATTEST:
DATE FILED
(Registrar of City or
' Jan. 12, 1962
r Town pmere death occur
occurred )
19..
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
CO.::
R-301
TIONS
l iSTIFICATE
living
DEATH
enter
dan one
e i r each
<1 and (e)
not mean
j 0/ dying,
rt I allure ,
It mean I
I or eompli-
I* canted
H any,
dr rite to
[re (a),
under-
le tail.
In I eontrib-
h but not '
’ terminal
ion given
,*>
I
apter 137,
requires
it to print or
tHc c«use or
o death on
ceM cates, and
Acta of
Phyai-
•r 1, t
rff'ea
nt or type
signature.
1
6 196; .
51 »MJ
\t$L t(.(oi.L.K
(County)
©17? ©mit^nmuraUJj ai Caficadjuarttfl
<f\ KEVIN H. WHITE
SECRETARY or THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
STANDARD
CERTIFICATE OF DEATH
Registered No.
or its Agent. ..
<>' >6? 8
U fto* BuB. y
U (City or Town)
-J A/aa ^ <«i i «ii i , - - ^ ((If death occurred in a hospital or institution*
ft- No. J £ W. \£hf. A(.ILjM.Q..£L\..Jn. L* ri.OS.Jp.X. T.rJJL St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
((Was deceased a
2 KI LL NAM K $a rtueL. ( U. S. War Veteran. No
( Ural Name) (Middle Name) (Last Name) (if so specify WAR)
(If chi raxil is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. ..iL. C 0 Rffift ftp* f U/J.NTW Rop .'
( I’sual place of abode)
Si.
(If nonresident, give city or town and State)
Length of stay: In place of death years f ...months.. days. In place of residence X... years months days.
MEDICAL CERTIFICATE OF DEATH
3 DEATH* F.. Xnuwnay H.jl~ !91 2.
(Month) (Day) (Year)
I HEREBY CERTIFY, That I attended deceased from
OBce/^&EA s. 19 u tojnHuu&y -2.0. 19^*2-
I last saw h*|"}alive on • S- Q, 19.*^^.., death is said to
have occurred on the date stated above, at m. | I....-..VAL
8 SEX
9 COLOR
10 CITIZEN
11 SINGLE
OF U S.
MARRIED
Male
i/hlte
YES 0 NO □
WIDOWED
DIVORCED
UNKNOWN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(.)
Hue To
(b)
SZTWEEN
| Ot;;ET A 113
DEATH
{oayx-
Due To
(c)
other Q QOt!£,Ho(rB NIC C A3 Cl Nt? TUI
SIGNIFICANT
conditions uyiyiy M &7Cti
//oMft)
Sss
Was autopsy performed?
What test confirmed diagnosis? e li /sj Cra L y -MiraPSy I
S Was disease or injury in any way related to occupation of deceased?
If so, specify
M. U
(Signed) _
/3 LgE tL.7 JM& foToA
. , (Print or i ype Name)
pi i'yi Pat e3.ft Attir.
6 . Sharon Park
Place of Burial or Cremation
January 21
Sharon
(City or Town)
DATE OF BURIAL
.19..
62
7 name of jlrnold Golov
FUNERAL DIRECTOR . ..Y
1668 Beacon St Brookline
ADDRESS
Recei
iZXaMSi
TTTT
""tCT'v
_ /V--J39..
A TRUE COPY ATTEST:
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(Husband's name in full)
i2 date of birth March 24,18v0
13
.71
9..M
77
AGE..L..r?.....Ye&r» .Z.Monthi..!^..(..H.Day
14 Usual
Occupation:
Hardware Dealer
(Kind of work done during most of working life)
IS Industry
or Ilusiness:
Retired
16 Social Security No. 01^12^99.1.9.-
17 BIRTHPLACE (City) -m
(State or country) N &VT YO^K
18 NAME OF-- ,, _. . .
father Hyman MacHott
19 BIRTHPLACE OF T3,mn4a
FATHER (City) .?±eL
(State or country)
20 MAIDEN NAME
OF MOTHER
Bescle C B L
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
22
Informant
(Address)
nd ii marricu, wiaowea, or aivorcea.. .. . , . .
husband of J5.ary.....Hl.r.e.h.o.yl.tz
(Give maiden name of wife in full)
(or) WIFE of
If under 24 hours
Hours. Minutes
I HEREBY CERTIFY that a satisfactory standyd certificate of death
was fij^dlwith me-ITEFOKE the burial or tranu'Lpcrmit was issued:
Agent of Board of Hea^i or
zZi?.../
(Official Designation) (Date of Issue of Permit)
1 kVuii
» V 4 -ri
'•P.
t. »
City Registrar
VY.
to:v-
py
■ ■" .... ^ <
•- :V> * - V.
~;9:T V-\ ^:x
+ O ^r/.|, r^<Sl ' ■/ *
MAR 16 1962 *H
I R-301 A
illCTIONS
DR
tl'.EBTIFICATI
n iving
•: F DEATH
»: enter
e tan one
itor etch
'!>) end (c)
i not meat,
■d »l dying,
i art failure,
•If' ^ mean I
U or compli- .
lick earned
:• hipter
uiree
cii to^print or
th elute or
* l i deith on
ctificatei. end
't I, Aet* of
retire* Phyal-
iO int or type
•'■*• signature.
15 - 1962
2
1145
lu Suffolk
)® (County)
Boston
(City or Town)
Qhimmrmuiraltij of iSaooartjiwrtto
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
OUT - OF - TOWN
To be filed for burial permit
with Board of Health
or ita Agent.
0/0%i •
2 FI LL NAME
STANDARD
CERTIFICATE OF DEATH Revered No.
yr*t - y> J ri* X ti . , , ((If deith occurred in a hospital or institution.
No. ... MH..„angX.and ken.ter JiQSpltal __ St.J give it* NAME instead of street and number)
PHYSICIAN — IMPORTANT
Samuel Tanker iu s. w^vne’an.
(First Name) (Middle Name) (Last Name) lif so specify WAR) TlO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. *7 Cottage AVC . , Winth.rQP, M»SSa
Usual place of abode)
0
^ months
St.
Length of stay : In place of death
years c months
days. In place of residence
(If nonresident
JJ1 ran months days.
Winthrop Mass
rsident. give city or town and Si
State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January
(Month)
31
(Day)
1962
(Year)
4 1 HEREBY C E R T I F Y , That I attended deceased Lrom
November. ,.2Q 19 61. to January.. .31 i9.6.2.
I last saw h ira live The text goes on. The rest is in the file.