The volume, 1963
Town Clerk, Winthrop · from the Internet Archive · 572 pages · 37.9 MB
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S52
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>RM R-303
for burial permit
Board of Health
r its Agent.
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Suffolk
(County)
% Win.t.hr..Q.p
(City or Town)
K
®! )e Comm jntoealtb of jfflatfgacljusiettji
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER S
CERTIFICATE OF DEATH
,<f- ~L?jO
(City or Town making this return)
1
Registered No.
No.
.17 Hillside Aye,
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME .DA VID E.. D.O.MEY. ((Was defeased
(First Name) (Middle Name) (Last Name)
(It deceased is a married, widowed or divorced woman, give also maiden name.)
•jU. S. War Veteran,
[if so specify WAR)
(a) Residence. No. 72..AuMm....S.t.*., Lynn.
(Usual place of abode)
...St.
(If nonresident, give city or town and State)
Length of stay. In place of death years months .^...days. In place of residence.s^"*A . years.. months. .0^?..... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ...
.January. 1, 1.9.63...
(Month) * (Dayf (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.)
Acute myocardial infarction.
9 SEX
10 COLOR
usU/7~<
11 SINGLE (write the word)
MARRIED
WIDOWED - J
DIVORCED rtf* e*
UNKNOWN
12 If married, widowed, or divorced , .
husband of LJvIpb+tr
(Give maiden name of wife in full)
(Husband’s name in full)
IF ACCIDENTAL, tvas injury causally related to the death?
Where did
Injury occur ?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or
public place?
(Specify type of place)
Manner of
Injury
(How did injury occur?)
Nature of
Injury
FATHER fr<i*lK V O'tt+I
3 T\ A l b a yi j
1/ * COx tfg /
20 BIRTHPLACE OF
FATHER (City)
(State or country)
21 MAIDEN NAME ,
OF MOTHER £ a'/’*! ■
22 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
•*rit +
C^ct/Za l\
9 PI
c.
7 £ r*
Place of Burial, <m-L
DATE OF BURIAL
>1
. 3UA
(City or Town)
wL3
23
Lo** * rtc K
Informant
(Address)
/ . V o Vw * Y
JL ^<4 ce vt cf ♦ rj j? idT.
FUNERAL DIRECTOR^ U 43 ?/*£ A ’ tO <* //
ss /P 3 iJ i> yi*S a\ £ f* LlM to.
ADDRESS
Received and filed JAM 2't363
A TRUE COPY ATTEST:
(Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filled with me BEFORE \fii burial or transit permit was issued:
.C^r. Sv.Cr.
signature of Agent n\ Board of HealthWr Afljer)
y/ / — ... * * 1 1 “ 1 u, iicaimeorcoiper; .
1_ J /y / 6 ^
(Official Designation) / (Date of Issue oy PCTijfht j
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
JAN-maffr
RULES OF PRACTICE
deaths caused directly or indirectly by traunmtism One f f j ^g* abortion, but also deaths from disease resulting
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 the nature of an injury and of its consequences, and ( ) fracture of the femur with ensuing septicemia
'i^P(S^rf“opS»: and disease o'r condition requiring surgery).- “Fracture of the skull
with associated internal injury sustained under circumstances unknown.
If disease or injury was related to option. liSSSto’
medico-legal "dSSffi »SL<S SfES (bisa, ganglta, (found dead ,» bed,."
“Heart disease, presumably coronary sclerosis. (Sudden death.)
ORM R-301
1 for burial permit
oard of Health
its Agent.
rRUCTIONS
FOR
L CERTIFICATE
r OR TYPE
OR CAUSES
DEATH
not enter
e than one
e for each
, (b) and (c)
does not mean
>de of dying,
heart failure,
, etc. It means
ase, or compli-
which caused
lions, i) any, 1
gave rise to I
cause (a), f
! the under- i
cause last. I
i ditions contrib- .
i death but not
to the terminal
condition given
•62-932382
Sty? (Enmttumuieaitli of HlaajsarljUHrttH
Suffolk
(County)
9. Wint.hr op
, (City or
£ no 39 Grovers Ave
KEVIN H. WHITE
Secretary or the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
SL
Registered No.
1
S (If death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
2 FULL NAME M!r.Q.i« HithQli^X
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
///' J ,
(a) Restdence. No 13 P COttfilge Park ... R.OM.
J (W
1 U.
V i f s
as deceased a
S. War Veteran,
specify WAR)....JjQ
..St..
(Usual place of abode)
Length of stay : In place of death year
(If nonresident, give city or town and State)
l.Q... months days. In place of residenc2.3-.years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January 6. 1963
(Month) (Day) (Year)
4 I
EREBY CERTIFY, That 1 attended deceased from
v>JT/.. , to* & 19..6.J.
I saw hfi^ali ve on .... (*> , 19. death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) L^arrri
Due,
(b)
ttno 4 Je. Y^atjs //&A)rt A* ? /oy
Due,
(c)
SIGNIFICANT T.h.c>Je.h
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
<rs
/o
/
Was autopsy performed? . ..
What test confirmed diagnosis? CS^.l
5 Was disease or injury in any way related to occupation of deceased? O
If so, specify ./).
‘ ^
(Signatur
Arthur C. Murray
Print of Type Name)
Date-A
M. D.
6 Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
January 9 19 63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS
Winthrop Mass.
Received and filed
JArf 8 19.
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOwmdowed
DIVORC
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
T (Give jaaiden*nameof wife in full)
(or) wife of James F tfahoney '
(Husband’s name in full)
12
AGE . 72a ears..
..Months..
..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :.
Housewife
( Kind of work done during most working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
nottlnghgmgland
17 NAME OF
father Frederick Plumbley
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
England
19 MAIDEN NAME
OF MOTHER ^ Smith
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
England.
21 Informant ... Barbara Cox
( Address)
136 Cottage Park Road, Winthrop
(Official Designation)
w/
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
~ ‘ni
I . ipfugnalure of Agent of Board of Heaith or other) '/ ,
(Date of Issue of Permit)
A TRUE COPY ATTEST:
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.
FORM R-301
Jed for burial permit
Board of Health
or its Agent.
NSTRUCTIONS
FOR
ICAL CERTIFICATE
NT OR TYPE
3E OR CAUSES
JF DEATH
do not enter
tore than one
ause for each
;a), (b) and (c)
is does not mean
mode oj dying,
as heart failure,
nia, etc. It means
lisease, or compli-
ts which caused
nditions, if any,
ich gave rise to |
we cause (a),
ting the under- |
ng cause last.
Conditions contrib-
to death but not
•d to the terminal
te condition given
2-62-932382
i
©Ij? (Enmtncnuitfaltlj nf HlaHBarljustfttB
la S.Uf.f.Qlk
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
3
(County)
Mint.hr.Qp
(City or Town)
MTMTURnP rnD/TMTTTMT'T'V UOC!'DTrPAT {(If death occurred in a hospital or institution,
No W .* .-I .IT Ic. V: h.. St. ) give its NAME instead of street and number)
t PHYSICIAN — IMPORTANT
2 FULL NAME L_ ..Cr.tt ( (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran, htci
26 Cliff Avenue,, Winthro8e^ «c.6°nald
... ivnvTff/iop MtiT*} — hjiuth^p Jh att
il nlace of abode) / (If nonresident, give city or town
sJ^.-.davs. In place of resident^..
(a) Residence.
(Usual place of abode)
Length of stay: In place of death years months^.. .days. In place of residents-. years..
(If
..months..
dent, give city or town and State)
..days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
&KTAH*
(Month)
(Year)
4 I HEREBY CERTIFY
PE c ^ 19..w to XA/s/^Afty 9 i
I last saw hfjjXlive on A'iv , 1^..5J, death i
have occurred on the date stated above, at ... MSP .m. \r
That I attended deceased from
L3
is said to
MSp'
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cardi a c FAiLi/n z
Due To
(b)
Due To
(c)
CpftOMAfly TAjIOMAoSI^
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
3U/KS
is/t?
Was autopsy performed?
What test confirmed diagnosis? Hui C-t A O GsAR DH>G~*A»i
5 Was disease or injury in any way related to occupation of deceased ?JWS
If so, specify ^
(Signature)
A >N
M. D.
(Address),
■ • (Print or Type Name)
ft A\
e .V/inthr.OT) .Ceme..t..exy..» W.i.^fbrpp , M
Place of Burial or Cremation (City or Town)
DATE OF BURIAL J.am&ry 11* 1.9..6.
7 NAME OF
FUNERAL DIRECTO
Received and filed
jtefi 1 i t96d
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED VV1 dowe d
WIDOWED
DIVORCED
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Lewis S.eabo.rn...le.i.tc.h...
(Husband’s name in full)
12
AGE,
Years QMonths [^Days
If under 24 hours
..Hours Minutes
13 Usual
Occupation:.
hpusewi*1^
(Kind of work done during most working life)
14 Industry ,
or Business: own home
15 Social Security No..
16 BIRTHPLACE (City)
(State or country)
-A..
s' ton '
' EassaGhusett's
17 NAME OF
FATHER
James McDon Id
18 BIRTHPLACE OF
FATHER (City)
(State or country) gj'fld
19 MAIDEN NAME
OF mother unable to obtain
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
England
21 Informant .Mrs
(Address)
.Eo.be.rt y.-Atcherley
164- WoQd3»de Ave»V/inthrop
1 7 j 1/4 0 4- + 1 HEREBY CERTIFY that a satisfactory standard certificate of death
ADDRESS .1 ..LA. nl.l >t.Or.Q.P a.t..»...:.'.l.n.t.hr.Q.P.» l|faS ga» filed with me BEFORE thy burial or transit permit was issued:
n'ltuLfoMj (J}
^Signature of Agent of Board of Health or other)
Jk
(Registrar) (Official Designation)
Ue of I^ei
A TRUE COPY ATTEST:
i* V
(Date of Issue of Permit)
\AV
SPACE FOR ADDITIONAL INFORMATION
date of entering military service
date of discharge
rank, rating
ORGANIZATION AND OUTFIT-
SERVICE NUMBER
frcn
i ,
-At %
i
- • • : ;
MS
rules of practice
KUUL3 KJI *
Tl« ■“ - T ‘SuttM
*■*
those of persons found dead.
, see explanatory instruct, ons
"ertificatVof death.
Statement vV^^Ffulness^f ^arSus ju^uU^can^e
-s;,rA.*- <«ssi swsi» “ SS4 ssjras
tion had been given UR , during most of working life ■ home. For a
1933 fH
unng most ui at school or at home, ror a
occupation by the *^°who had no occupation whatever wr
r
FORM R-301
iled for burial permit
i Board of Health
or it* Agent.
INSTRUCTIONS
FOR
ICAL CERTIFICATE
INT OR TYPE
SE OR CAUSES
OF DEATH
do not enter
nore than one
:ause for each
(a), (b) and (c)
iij does not mean
mode of dying,
as heart failure,
•nia, etc. It means
disease, or compli- 'p
•ns which caused
h.
mditions, if any, 1
Hich gave rise to f
•ove cause fa), f
sting the under- l
ing cause last. '
Conditions contrib-
t to death but not
ed to the terminal
ise condition given
«).
* 2-62-932362
Suffolk
®ljr (Enmmnmurdtlj nf JSaaaarijHHetla
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
4..
Registered No.
No IiQ.im.tlS OQnYflL!ea.C£Jlt L.OIiS death occurred in a hospital or institution
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name Lillian Nancy Poley ( McC ormick )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
t;/W
(Was de
\ U. S. W
V > f so spe
deceased a
ar Veteran, r\
specify WAR) a,\SJ..0...
(a) Residence. No Trident Avenue st linthrop., Mass..*
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death.^ years....6.. months days. In place of residence.5-5years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T
death January IQ.
(Month) (Day)
(Year)
4.J HEREBY C £_R T 1 F Y , That 1 , attended deceased fro
ire O ,J Y fp
I last saw h<5Ralive on ... jrfw: /p death is said
have occurred on the date stated above, at ..J^. // m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a,
Due To
(b)
e A Mm yyd) ,
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
r cLtiacs/s -c tN
INTERVAL
BETWEEN
ONSET AND
DEATH
to*
Was autopsy performed?
What test confirmed diagnosis?
JW'
fifty
5 Was disease or injury in any way related to occupation of deceased
If so, specify
W»-i
(Signature)
t/l2 liA
6 Holy Cross Cemetery Malden
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTO
174 Winthrop 2rt. Winthrop, Mass
A D D R ESS ir.
Received and filed .... dA^4""'l'
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIEDW1
WIDOWED
DIVORCED
UNKNOWN
(write the woid)
“ dowea
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Timothy Poley
(Husband’s name in full)
12
AGE . QQears rJ... Months. ..2*^ Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
housewife
(Kind of work done during most working life)
14 Industry
or Business:
own home
IS Social Security No..
16 BIRTHPLACE (City).
(State or country)
none
Boston
Mas a -
17 NAME OF
FATHER
.Tampa Vp.rinrmi p.lf
18 BIRTHPLACE OF
FATHER (City)
(State or country) Ireland
19 MAIDEN NAME
OF MOTHER
Mary Daley
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Irel ,md
21 Informant .Old Age . De p t .
(Address)
ainthrori. T,; f\,\ S D chll.SP ttS-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with life BEFORE the burial or transit permit. was issued:
. <T, afJflL
^Signature of Agent of Board of Health or other)
CU c7f :
(Date of Issue of Permit) ,
/>
(Official Designation)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE,!^^.
DATE OF DISCHARGE Sfe 1«
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
- ••• ^ v-
i • , A
Z'fr
[ 6 PSA'-
RULW&T-k<ACTICE
The fulfillment of the purpaseiof.thjsp Iws Saills for the observance of the
following rules of practice: JAiy i.ZlIQn'i h! .
(1) Attending phyeiciantWilLceTtir^* r<V^iwi aeaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury. , , ,
(2) Board of Health physician* will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form pi
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, ror 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
> v ■%
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a 2tyr (Enttrotmtwraltli of Hlaasarljufirtla
JOSEPH D. WARD Danvers
Secretary of the Commonwealth »..».:.....ia.**.x..s?.*..«.. ...
DIVISION OF VITAL STATISTICS (C'ty °r T°Wn mak‘n* th’S retUrn)
COPY OF
(City or Town) CERTIFICATE OF DEATH Registered No *1
No.P.S.ny.e.r.a. Stete &G3.p.l.tal, .Hs..thcrna....st. {'
2 FULL NAME ^.Q.ll.J-.S
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was
)U. S. 1
Vif so
deceased a
War Veteran,
N— specify WAR,
(a, Residence. No ^ Dpiy® /....W i P, t.hr.Op., Mfi.
(Usual place of abode)
^ vpflr# mnnths .2.0.
S3.*
(If nonresident, give city or town and State)
Length of stay: In place of death.. .7r.....years months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
Janus rv 11* 19.6.3
(Month) (Day) (Year)
4 I HEREBY CERTIFY. That I attended deceased from
Hov». 21*.... 19.62..f to..Jft.n.ue.ry....l.l* w.6
i9....63i
. a?*.S.Qp..,....m.
I last saw fT.^.^live on
have occurred on the date stated above
tteath is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Vlrsl Pneumonic
(a)
du^ General / rterl pscleposis
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
-w
INTERVAL
BETWEEN
ONSET AND
DEATH
ro~
Was autopsy performed
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?
If so. si^if:
JlTIflii, .;. m. D.
Kr thorne,Mrss . l/l^/ 63
(Address) Date TT. 19
,M.D.
Bepchmont Cemetery, 1 verett
Place of Burial or Cremation
DATE OF BURIAL
■r (Cuy»pr Town) , _
Jrnuery 13, ,63
7 name of Torf Punerel Home
FUNERAL DIRECTOR ,Q
ADDRESS
Received and filed
FEB 6 1963
.19..
• Registrar of City or Town where deceased resided)
8 SEX
ernsle
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED
or divorce^ idnwftd
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Julius... .Hollis
(Husband’s name in full)
(or) WIFE of..
11 IF STILLBORN, enter that fact here.
A GE0.lt... Yea rs3. Months. .21). Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Seles ClerR:
( Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
' t T>e t e rmihe
16 BIRTHPLACE (City)
(State or country) utsoAcI
17 NAME OF
FATHER
^orris Meson
18 BIRTHPLACE OF
FATHER (City)—
(State or country ft!! S S 3.8
19 MAIDEN NAME
of mother bertha Shirley
21
20 BIRTHPLACE OF
MOTHER (City -Q- g
( State or country; °
Me rv V. Sy-e ehe n
Informant
( Address
? Hg thorne , Mass ,
A TRUE COPY
ATTEST:
■
i^S(^gisti^an^f Ciify oT'fown whyre death occurred)
DATE FILED January... .1.7.# i» 6.3
/x
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L. )
R-302
IX
r
lu F.S.SL&iX;
]0 (County)
/d.
)° P.s.n.y.er.a
I o (City or Town)
Wijt (Enmmonuiraltlj nf fHafifiarljuflrtta
JOSEPH D. WARD
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
IVry:.e..r.s
(City or Town making this return)
Registered No.
NoD.an.Y.e.r.s S..t.s...te .H.o.ap.i.ta.1., Ha.thar.rDB... ..St. { give its NAME instead of stree
<;
or institution,
street and number)
2 FULL NAME. .. Ge.rt.rud.e.....Ea.y
(If deceased is a married, widowed or divorced woman, give also maiden name.)
deceased a
War Veteran.
specify WAR,
(a> Residence. No 12Q.....Gl.r.c.ui.t....Ilaad /... jtfl.n.thro.p.* M£.3..s.»
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death. li years. ..^....months9. days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ...
January 12* 1. 9.6.3.
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
April 3.C.* 19.6,1.., to...J.^.nus.ry.....l2..,, 19.6.3...
I last saw fr..r.aljve on l.£-..> 19vP..J5., death is said tc
8 SEX
fe rifle
9 COLOR
wh* te
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED HP T,V,J ed
have occurred on the date stated above,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Pneuironla
?b r frrterloaclerotlc heart di qeese
Due
(c)
General A^terloscleros Is
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Jr.fn.es Fay
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AG
S3
..Yearsjl Months
.6.
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
-Dorchester
16 BIRTHPLACE (City) ...^o.r. ' .^.7..'
(State or country) S S •
Was autopsy performed? ..X4.Q..
What test confirmed diagnosis? .
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
"JIJ i^rd 1% Hr us men
» IHIard -13.. n~us.ma.21..
(Signed) Jt _L.i..±.LI.X!U £S.» M. D.
K.a.thorneJ(.^s.p.f. Date. ..1/15/ 19...6.]
( Address)
6 Winthrap c.c.ra.a..t;.©.r.y..# ll.nth.rQ.p
Place of Burial or Cremation (City or Town)
J&nu.er.y....!£j 1S
17 NAME OF
FATHER
M,
:eeney
18 BIRTHPLACE OF
FATHER (City)
( State or country ) i'4© 3 S *
19 MAIDEN NAME
of mother i-1 i 7 r be th ( Un known )
DATE OF BURIAL
NAME OF
FUNERAL DIRECTOR
ADDRESS
1 Fie ley rinne r e 1 Heme
‘‘"a* :V
Ph
20 BIRTHPLACE OF
MOTHER (City)
Unknown
(State or country)
Unknown
21 Xf ry L„
Sh&ehen
(Address) UnOTTle
t ft&ss •
A TRUE CO£Y-^ . /-)
ATTEST : ■■■■/■.
i ( Registrftt1 or City or Town y here death occurred )
DATE FILED January 1 7> 19 6.3
Received and filed
(Registrar of City or Town where deceased resided)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
rORM R-301
I for burial permit
oard of Health
iti Agent.
HIUCTIONS
FOR
L CERTIFICATE
r OR TYPE
OR CAUSES
DEATH
not enter
e than one
ie for each
, (b) and (c)
does not mean
> de of dying,
heart failure,
, etc. It means
ase, or compli- ^
which caused
tions, if any, 1
gave rise to I
cause (a), f
f the under- I
cause last. '
iditions contrib- ^
i death but not
to the terminal
condition given
M •c*'
■62-932382
QJfj? (Hmnmnttuiraltfj nf HHaafiarijUBPttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
7.
Suffolk
(County)
p Winthrop
(Chy or Town) VWJf CERTIFICATE OF DEATH Reg.stered No.
no Winthrop Community Hospital St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Martin e, Slattery.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
YSIC
J(V
w
(Was deceased a
S. War Veteran,
so specify WAR)...
MaJsLx.
(a)
Residence. No 155 River RcU st Winthrop, Mass
(Usual place of abode) i ' / , (If nonresident, give city or towr
Length of stay: In place of death years months days. In place of residence years months days.
town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF -r- /{ L
DEATH J A ...
Ol
, ll.k.3
8 SEX
9 COLOR
10 SINGLE
MARRIED
(write the word)
married
(Month)
(Day)
(Year)
male
white
WIDOWED
4 I HEREBY CERTIFY^
That I
A £/
attended deceased from
> -V .. /
A-I X V i\ 1 1 . 1J
UNKNOWN
I last saw hhri., alive on y , 19.4.3, death is said to
have occurred on the date stated above, at m. INTERVAL
BETWEEN
ONSET AND
DEATH
ISkvs
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
.^<g..^...g.cy..V.//^.^.(Q..
Due
(b)
Y-vy-fe-
Due To
(c)
OTHER
SIGNIFICANT PkJ.in.Qi.
condition^* M V /<° rtf i<//,7),x<igAig
Was autopsy performed?
What test confirmed diagnosis
m.
i^fv> ■
12
AGE. (ryfi.. Years
Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Accountant
(retired)
(Kind of work done during most working life)
14 Industrv
or Business:
IS Social Security
No c
S Was disease or injury in any way related to occupation of deceased Vi......
If so, specify ......x..
(Signature)
, M. D.
r±U..Ad.L£..S. LlQ..£.K..AIA.A
(Print or Type Name)
(Address) l l../7V.l://^|?y..^/4..^J...DateJ!.HV|.a../.^. \9.k3..
6 ...Hand in....HaM> West,,Roxbury
Place of Burial or Cremation (City or Town)
date of burial January - -IT. 19....43
7 funeral director He..Qi§$.iTL.l. .• Solomon
ADDRESS ■li2Q....Har.¥.ar.d...H.tr.e..?..t..> Brookline
Received and filed .... JAN 14 49ho
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced.. . t i
HUSBAND of .to.lM...tebrO
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
16 BIRTHPLACE (City).
(State or country)
i t -• '■ .
17 NAME OF
FATHER
Edward Slattery
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Mary Sahey
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
..Boston-,
Mass .
21 Informant ,.Mirl.am....Slat.te.ry
(Address)
l£5> River Road, Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fil^d with me BEFORE the burial or transit permit was issued:
.,.4 :
(Signature of Agent of Board of Health or other)
fez Ll.hJ±£.£...
(Date of Issue/of Permit)
l
(Official Designation)
✓
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.^^Ill:
DATE OF DISCHARGE JAN'i‘4'f263"Af1
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
~\ uv
£-.50-1.35/
. . . ^ . . . i X . . . . r'
RULES OF PRACTICE
■ > ■ 6 ■« .
The fulfillment of the purpose of thesje laws calls for the observance of the
following rules of practice: / j
(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 t<rtify-?o .JiSch TlfejathM only as those of
persons who, though disabled by recogniiM cRs^gsejuniilate'd 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.
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L. )
R-302
Ess.ax.
(County)
Danvers
(City or Town)
Sty? Qlmnmnnumiltij nf HaaaarljuHrttR
JOSEPH D. WARD p ..
Secretary of the Commonwealth ....... MrTl.'/.e.P.a...
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No
Hsthorne... ..St. } give its NAME instead of street and number)
8
2 FULL NAME. .. Fr.enk.....?.*....H.all.Q.t.t.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
deceased a
War Veteran,
specify WAR,
(a) Residence. No. ,...S.8....0.t.ia st....Winfchrop# Msaa*
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years.-5....monthsl2..days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
EeI?h0F. J.a.nue.ry. .1.8., .19.6.3
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
19.62.., to..J.anua.ry.....l8.# 196.3...
I last saw h..vki}live on l.Q.f...., 16.3. death is said to|
have occurred on the date stated above, at 8:.U5.e... .n
8 SEX
male
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED DIF) T>T* * fid
10a If married, widowed, o*>di\mrced
HUSBAND of .V.nKD.QWn.
(Give maiden name of wife in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
General Arteriosclerosis
(a)
Due
(b)
T.^.r.teri.Q.s^
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
30336
Was autopsy performed?^?.©....
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
Fillfcu-d tim ^euSmen
( Signed r*
(AddreSJ?et.hprne.,.Mess,..
., M. D.
Dat e.. 19. .6.3.
6 ..^.i.h.thrpp .....Cemetery., Wlnthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
nuery...?.!, 19.6.3.
name of Alfred B Kprsb
FUN ERAL DIRECTOR ...£.. ..7... ”.Y _.*...... . .f....1.
ADDRESS
.,k ln.th.rop..
Received and filed ... FEB 6
(Registrar of City or Town where deceased resided)
,.19..
(or) WIFE of..
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
:7.8...Years....3.
Years. .. Months.. L./.. Days
1.7.1
If under 24 hours
Hours Minutes
Occupation: l.lrMuce .(Whol.0.a.8.1ft.)
( Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
re It
16 BIRTHPLACE (City)
(State or country) 1 S S »
17 NAME OF
FATHER
barren Halle tt
18 BIRTHPLACE OFQ Q j
FATHER (City) Z.. r.
(State or country) Mass.
19 MAIDEN NAME
OF MOTHER Nellie Burse
20 BIRTHPLACE OFn ,
MOTHER (City)
(State or country) A if) S S «
21
Informant
( Address
A TRUE COPY
ATTEST:
DATE FILED
I#
egistrar of ^ty'or Town where death occurred)
Jsnuery. 25, i».A3
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ORM R-301
for burial permit
ard of Health
ts Agent.
MUCTI0NS
FOR
L CERTIFICATE
r OR TYPE
OR CAUSES
DEATH
not enter
e than one
;e for each
, (b) and (c)
does not mean
<de o) dying,
heart I allure,
, etc. It means
ase, or compli-
which caused
tions, if any, 1
gave rise to I
cause (a), r
r the under- |
cause last. )
ditions contrib-
* death but not ^
to the terminal
condition given
■62-933U0U
®1jf (EmnmmuuEaltlj af fHaafiarfyuBrttB
(City <
No..
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
< Aao a /7 dlii
S U'/ATUtf//0 WK STANDARD
'«■** (Ci'Ao/fb'Zn) CERTIFICATE OF DEATH Registered No
//> /A/ /l 0 £)/^l f~/A C ■£* r. ((If. death occurred in a hospital or institution,
. SrC C ,.y..../A.CJ.^..TZ.. St. ( give its NAME instead of street and number)
2 FULL NAME..
PHYSICIAN — IMPORTANT
(If deceased is a married, widoiVed or divorced woman/give also maiden name.)
(Was deceased a
U. S. War Veteran, /Y / T
if so specify WAR) Sc
(a) Residence. No ^1...^/... JU...CA1L... Sr s. li/A.
(Usual place/of abode)
Length of stay: In place of death years months..-X-days. In place of residencey.T^Cyears months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEAT
3 iI))eIth,k. January 18, 1963
(Month) (Day)
(Year)
•4 1 H E R E 1! Y CERTIFY, That 1 attended deceased from
..June 19.5.8 to. January 1.8.., 19...63...
I last saw h0J£?hve on ... Join* l8, 19...63^eath is said to
have occurred on the date stated above, at . l.:..Q.8..p ,.m.
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Acute ^eft ventricular
dilatation
INTERVAL
BETWEEN
ONSET AND
DEATH
m.i nut
a e$Gl^t^^^\'ezirs Months Days
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED i
DIVORCED
UNKNOWN D/^A'Q
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of [...£2
(Husband’s name in full)
12
If under 24 hours
Hours Minutes
(b)^.o.Qard.ial heart disease.
I,mRheumatic heart disease.
13 Usual
Occupation:.
(Kind of work done during most of iworking life)
(c)
yrs
14 Industry
or Business:
r/ / Oa
SIGNIFICANT pne u mo n4 1 is , hepa.t o -
conditions megalv with jaundice
4-5
days
15 Social Security
16 BIRTHPLACE (City).
(State or country)
'a - 1; ?
Was autopsy performed?
W'hat test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?Nq
If so, specif’
(Signature) p
... M. D.
eph ..Gr e£0f i e , JL D .
(Print or type Name)
(Address) 1.9A.....Wash.ing.jE.QA Date Jan. I9 196.3
ion (City or I own)
zi i9
17 NAME OF
FATHER yJrjMBS 7A ^
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER jfA/////- /*-f jL/S
20 BIRTHPLACE OF
MOTHER (City) .S
(State or country) /7 J J
Place of Burial or Cremation
X
DATE OF BURIAL
21 Informant
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
t.( /T/m
(Addre
Ss7.. .#
Received and filed
JAN 2 11963
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with ine BEFORE the burial or transit permit was issued:
'(Signature of Agent of Board of Health or other)
'\3
( Registrar)
(Official Designation)
BK
(Date of Issue of Permit)
/ M
7
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
;c \ O'//.-.
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 onlthai t^ibsl dQftfJoiilJ
to whom they have given bedside care during a last ilmfii'frwn-siiseiSeJunl1
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 CauK 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.
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L. )
r
R-302
%
Saafix..
(County)
i° Pcnge.ES..
/ c_> (City or Town)
2% (Smmmntumtltlj at
JOSEPH D. WARD p
Secretary of the Commonwealth */£U3.V.fi.ES.
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
to
No..P.3B.5!.s.r.a S.t£.t.s b.o.s..p.I.tal.* Iia.th.Q.r.na...st.
tficheel Eruzione
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
No
FULL NAME ! „..Tr. ..n...%.M..r..y.f.f" ) (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) jU. S. War Veteran.
\if so specify WAR,..
(a) Residence. No.. .....2..7h.-BoMd.Qln st..\iI.n.t.b.7.o.p., Mas-cu
(Usual place of abode) (If nonresident, give city or town and State)
In place of death years months. n •days. In place of residence years months days.
Length of stay:
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
January 2?* 1963
(Month) (Day) (Year)
4 I HEREBY CERTIFY.
That I attended deceased from
Jep?j.f.ry....i.i 19.41. 19 .5.1
l.Talive on 19.6.3.
I last saw hr.
have occurred on the date stated above, at ' *...m.
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
, Arteriosclerotic heart disease
(a)
Due To
(b) ....
Due To
(c)
significant P.n.ch ppneumpnl e
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
years
^ O rj ry
3
If under 24 hours
AGE..X..f.Years
. ...Months... .v
/...Days
Hours Minutes
days
What test confirmed diagnosis
Was autopsy performed '
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
Wf
(Signed) i:.
( Address)
r rd - ^rus-nr
•...il.lr..r..a ...L...fkuSM;..o..
.19
M. D.
63
5a thornoy ^ass . Date^.Z.?^Z
H 01 T . Cross C etr,e t ^ ry , Milder, •
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
Vjh 1 t P
10 SINGLE (write the word)
MARRIED
WIDOWED . . . J _ . . — >3
or DIVORCED WlCIOW©U
10a If married, widowetL <lr.lMvorcad
HUSBAND of
or divorced . r% 3 _ •
".QP.Qer.t£....Criss i
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
13 Usual
Occupation:
h a und ry W o r ke r
( Kind of work done during most of working life )
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City)
( State or country)
spies
Tfily
Place of Burial or Cremation
DATE OF BURIAL
_ (City y Town) .
i^nuary 2 6 , 19 6 3
NAME OF
FUNERAL DIRECTOR
ADDRESS
Vircent ~apino
r'. Fll'ton# “Ha'Ii'i'
Received and filed . FEB 6 1963
(Registrar of City or Town where deceased resided)
.19..
17 NAME OF
FATHER
Vincent ^ru alone
try IS BIRTHPLACE OF Unknown
FATHER (City)
(State or country) I te 1 y
19 MAIDEN NAME
OF MOTHER
MPrie, maiden name unk
21
20 BIRTHPLACE OF TT ,
MOTHER (City! fetolOWn
(State or country) ‘'F Xy
Sveehrn
Informant
(Address)
"5a ry . . . _ _
A TRUE COPY
ATTEST
: Qtf&riteUrd.'..
(Registrar of Cit^or'Town where death occurred)
date filed January 2X>, 19. 63
a i
SPACE FOR ADDITIONAL INFORMATION ...f.£0-^v43S3U^
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
4R-301A
RUCTIONS
FOR
. CERTIFICATE
giving
OF DEATH
lot enter
than one
: for each
(b) and (c)
does not moan
\t ol dying,
heart failure,
etc. It means .
se, or compli- *
which caused
ons, if any,
gave rise to
cause (a),
the under-
cause last.
tions contrib-'
death but not
o the terminal
ondition given
Chapter 137,
1954, requires
ins to print or
le cause or
of death on
irtificates.
c. •
i
2 FULL NAME-
Suffolk
(County)
Win t hr op
GJlje (tatmamuraltlj of fHaaaarljuarttH
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town)
Crest Haven Rest Home
No
Florence A (Noyes) Brown
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
it
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No....'
66 Winthrop Shore Drive
f (If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
! PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
— St.
(Usual place of abode) ., -. (If nonresident, give city or town and State)
5 . lo
Length of stay: In place of death years months days. In place of residence — years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
(Month)
c X3_
(Pay)
(Year)
That I attended deceased from
M 2-3 , 19^ 3
4 I HEREBY CERTIFY
... A/O 'J I , 19 to
I last saw h^falive on vi . -3- y , . is , death is said to
have occurred on the date stated -above, at S"\£ o ff m-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) o .se! /*'c ftiZaYT"
f x TD ftS<£. .
Due To'J
(b)
W h v v e H esech
n 3D tv seo.se.
Due To
(c)
sk]m fi cAN-k?^^ bYc h&Llcissi-te.vioJ’Js.
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
YS
S<
. c .
Q 1 1 K X CL-A. \
Was autopsy performed? i.
What test confirmed diagnosis?-
5 Was disease or injury in any way related to occupation of deceased
If so, specify ...
(Signed) —
(Address) ^w~WWY<V|> VUfl S<,
Date
6 uinihmp. ...
Place of Burial or Cremation
DATE OF BURIAL
_, M. D.
... Jinthrop
(City or Town)
Jan. 25
6 \
7 NAME OF
FUNERAL DIRECTOR
Hov/ard_5_ Reynold s_
ADDRESS
j iinthr oja, Mass.
Received and filed
JAN 25 1963
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED - r • j .
WIDOWED . lOOU
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Edgar_B _Br own
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 79 6 10
AGE Years Months Days
If under 24 hours
Hours Minutes
13 Occupation: HOUSeWife
(Kind of work done during most of working life)
14 Industry ^ hOIiie
or Business:
15 Social Security No..
003-14-331 o
16 BIRTHPLACE (City)_...rjIS.fi'eX.Spn_
(State or country) i..£me
17 NAME OF
father Charle:
F Noyes
18 BIRTHPLACE OF
father (City) Js.4
(State or country) fa -j np.
19 MAIDEN NAME
OF MOTHER
Josephine Hovie Clary
20 BIRTHPLACE OF
mother (City) Unable to obtain
(State or country) J- . f (VI:,
21
Informant HalphRQaCh
(Address) 3 Or ant R- .
frieia7 Rais'
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fil^d with me^BEFOJlE the bririal or transit permit was issued:
;.ALl
^nature of Agent of Board of Health or otheY)
>V
(Official Designation)
j c. /. y A 2
(D*fe of Issue of Permit) , ^
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age, the
disease of which he died, defined as required by section one, where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law, or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. . — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall. b^ry'a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from.the.clerk of the town where the body is to be buried
or the funeral is to be held, or frim a person appointed to have the care of the
cemetery or burial ground in which the interment is made.
. . . Chap. 114, Sec. 46, G. I^,-, (Tercentenary Edition).
RULES OF PRACTICE
• - \ ■ -V*
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
( 1 ) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside ;car.e 4uring 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 re'ceiit 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 intrUiJ^a ijqtferklp> tfy^caused directly or indirectly by
traumatism (including s^tnee^itjib , ,^nd by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ORM R-301
M
&
for burial permit
>ard of Health
its Agent.
RUCTIONS
FOR
. CERTIFICATE
OR TYPE
OR CAUSES
DEATH
not enter
: than one
e for each
(b) and (c)
loes not mean
ie of dying,
heart failure,
etc. It means
ise, or compli-
which caused
ions, if any,
gave rise to |
cause la),
the under- I
cause last.
ditions contrib- ^
death but not
0 the terminal
'.ondition given
If
Ri:
62-932302
Uimttmmtuimiii ni
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Suffolk
(County)
Winthr op
(City or Town) CERTIFICATE OF DEATH Registered No.
Hospital
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
12
2 FULL NAME.. . Jeaneppe Loess.!. Johnston / (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran, fJo
s|«city WARi
(a) Residence. No _P.?.Q.. ....- 3rd Floor F ort Banks st Mnt.hr..Q.p..,Ma.s..s..
PHYSICIAN — IMPORTANT
(Usual place of abode)
Length of stay : In place of death years months.3 days. In place of residence **years.
(If nonresident, give city or town and State)
months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
ZJZ..
(Month)
25...
(Day)
1963
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
':^^....'V.Qr...., i9...S^.f to^Osi* IrA i9..k^....
I last saw h^r.^alive on ^..&..toin..S. , 19.. ip death is said to
have occurred on the date stated above, at )...D.......!^A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
[a) th.'T emW.-Swh
Due To
(c)
OTHER v OT^2. ro tT \ <X' x \
SIGNIFICANT
CONDITIONS^ wyo\ :
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis ? A.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
B”
U ’ JT^v,nel'c
(Print or.Type Yiame)
(Address) lASr.St.S:. Date.....V..'..>..^..
.., M. D.
..19.Lt.*?..
6 .For est Hills Crema tor v E o s t on
Place of Burial or Cremation (City or Tov]W]£ S S •
date of burial . ... January 28,..
.19!
63
FUNERAL DIRECTOR .J..*..£:. •.Yf.®..k .©.?! H.‘. S.On.S .
a ddr ess .E..p..s.tpn^.ftia..s.s..*
Received and filed
m 28 1963
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWEDn-
divorceeUi vorc ed.
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife ^Charles Ru Johnston
(Husband's name in full)
AGE...4.&rears 5.... Months 24d
ays
If under 24 hours
Hours Minutes
Occupation: Librarian
(Kind of work done during most working life)
1 4 or ^Business : Fo r t ..... Banks , Wi nth r o p , JV” a s s •
15 Social Security No. 15 6 -IQ- 5 917
16
BIRTHPLACE (City)..B.O S t-OIl.
(State or country)
Ma s s
17 NAME OF . ,
father Cannot be learned Loessl
18 BIRTHPLACE OF -f . ,
FATHER (City) .....kUni.C.n
(State or country) Germany
19 MAIDEN NAME
of mother Eertha Petrol
20 BIRTHPLACE OF c , -. ,
MOTHER (City)....y.U-LSe±d
(State or country) GemiariV
21 Informant
(Address)
Charles Snyder
10 Riverdale F<d. , Cone or ri, Mass .
:eby certif
ed with me BI
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me 9EFORE the burial or transit permit was issued:
-
(Signature of Agent of Board of Health or other)
/
(Official Designation)
(Date of Issue
£.toZXkto..
of Permit)
A TRUE COPY ATTEST:
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 from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
>RM R-304
In giving
CAUSE OF
!TAL DEATH
do not enter
nore than one
ause for each
of (a), (b)
and (c)
tal or maternal ,
i dition causing
tal death (do
if use such
ms as stillbirthl
prematurity.) !
tal and/or ma- .
nal conditions ,
my, which gave'
s e to above
j se (a), stating
e underlying
use last.
> editions of fetus
mother which
i y have con t rib -
' e d to fetal
ath, but, in so
r as is known,
•re not related
cause given
(a).
5M-6-60-928241
ill
« Suffolk
W (County)
“ Winthrop
U-t (City or Town)
iO
®l|e Commonteealtl] of ^Massachusetts
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
CERTIFICATE OF FETAL DEATH
(STILLBIRTH)
To be filed for burial permit with
Board of Health or its Agent.
Registered No.
13..
[5 no. Winthrop Community Hospital
t J
2 name OF fetus Baby Boy Miller
(if given)
St. j
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
3 DATE OF 1 26 1963
DELIVERY
( Month )
(Day)
(Year)
4 SEX
Male MFemale Undetermined
5 COLOR (if v.T
determined) W
6 THIS BHfcTH (Check one)
Single JL Twin Triplet
7 IF MULTIPLE BIRTH, BORN:
1st 2nd 3rd
FATHER
8
FULL
name Herbert Miller
192 Constitution Avostreet
RESIDENCE, NO.
city or town Revsr© state Mass
10 COLOR or
RACE
Wh.
11 AGE AT TIME OF Td
THIS DELIVERY JQ
(Years)
12 PLACE OF
BIRTH
Chelsea
(City or Town)
Mass •
(State or country)
OCCUPATION
Laborer
14
MOTHER
maiden name Teresa Joyce
Teresa Miller
PRESENT NAME
residence, no192 Constitution Av&treet
city or town Rev er e state Mass..
16 COLOR OR
RACE
Wh
17 AGE AT TIME OF
THIS DELIVERY
32
(Years)
18 PLACE OF -r, , „
birth Roxbury
(City or Town)
Mass •
(State or country f
19
informant Herbert Miller
20 PREVIOUS DELIVERIES TO MOTHER
f Do not include this fetus)
(a) How many children are
now living? J
(b) How many children were
born alive but are now
dead? QJ
(c) How many previous fetal
deaths of ANY gestation
age?
21 LENGTH OF
PREjGfNANCY
L^completed weeks
22 WEIGHT OF FBTUS
Lb. /f Oz.
Tor . . . r' '
’Grams)
23 WHEN DID FETUS DIE?
Before 1 ./During Labor
Labor or Delivery Unknown
24 AUTOPSY . ^
Yes No/L^^
25 FETAL DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a
Due To (b) .
Due To (c)
OTHER SIGNIFICANT
CONDITIONS
27 NAME OF
FUNERAL DIRECTOR
ADDRESS
Tit
Received and filed
A TRUE COPY ATTEST:
JAN 29 1963
( Registrar )
I HEREBY CERTIFY that this delivery occurred on the date stated
above at , and product of conception was not a live birth.
•f
Signature of Attending Physician or Medical Examiner:
■ n'"£jLjL
M.D.
X j tM/o A ' X //<,'
' (PRINT OR TYPE SIGNATUwo, .
Ajji < '/*' ’•£.
/./ V a nrrt* y? A si'//*-*
Addres
I HEREBY CERTIFY that a satisfactory certificate of fetal death
was filed with me BEFORE the burial or transit permit was issued:
i ,
(Signature of Agent of Board of Health or othfcr)
,jj0ate of Issue of Permit)
( Official Jl^ignation)
f
FETAU DEATH
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48.
. . f .1 'i
ACTS OF 1960. ' . .
Section 2 A. “Examination of records and returns of illegitimate births, or abnormal
sex births, or fetal deaths, . . . shall not.be pgkmitted except . .
,V
Section 9 A. When a child is born dead, after a period of gestation of not less than
twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and
no movement of voluntary muscle, thJ^Jiysre|an^)r officer attending at the birth of such
child shall forthwith furnish for registration^ at? m'e request of an undertaker or other
authorized person or of any member of the family of the deceased, a certificate of fetal
death on a form which shall be prepared by the secretary of state as required by section
sixteen. Town clerks shall record certificates of fetal death in the town register of deaths
in the same manner as a death certificate, but they shall not be required to record such
certificates in the town register of births.
Section 12. “. . . No birth record of a child born out of wedlock or of a child of
abnormal sex, and no record of fetal death shall so be transmitted to any other city or
town.”
Section 2U. In any statement of births, deaths and fetal deaths printed by a town the
name of an illegitimate child or of its parents or of the parents of a child born dead shall
not be printed, but the word “illegitimate” or “fetal death” shall be used in place thereof.
A town violating this section shall forfeit to the mother of such child not more than one
hundred dollars.
FORM R-301
I for burial permit
oard of Health
its Agent.
TRUCTIONS v,‘
FOR
lL CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
-e than one
se for each
i, (b) and (c)
. , (If .deceased is a married, widowed or divorced woman, give also maiden name.)
/ - 4
$L.k. ;1:1 s
does not mean
ode of dying,
r heart failure,
i, etc. It means
tase, or compli-
which caused
itions, if any,
i gave rise to
cause (a),
g the under-
cause last.
nditions contrib-
o death but not '
to the terminal
condition given
*
c ,
-62-932382
|W/I
r Tow#)
J....&.
(£flmmmuu?altJf ai fSaaBadjuarttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH Registered No
t | (If death occurred in a hospital or institution,
rr... i St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
..) (Was
) U. S.
(if so
as deceased a
War Veteran,
specify WAR)..
(a)
Residence. No.. _
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death... £ .years.. ..TTTTmonths Todays. In place of residence. .^....yearsr. months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
i» al.7.
(Month) (Day) ' (Year)
HEREBY CERT IF That. 1 attended deceased from
.oJM..li vUA....
t./aeath is said to
I last saw h.i/Mlive on _ r. „ t
have occurred on the date stated above, at IXs-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Due To
(b)
Due To
(c)
OTHER i I - ^
significant ..p>...Q.M.s,..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased^C^
• If so, specify
fr"-*’ "■ u
> <^».>
7/Uiu.c X f
(City or Town)
&
Received and filed
SkH 28 1963
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SlNOUs- -
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
!u
1> V tx ^
1 1 If married, widowed, flr divorced C"1 i
HUSBAND of h7r.(7Mf^ XX X.
(Olye maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
AGE^ j...Y
ears ...Months Days
13 Usual
Occupation^.
If under 24 hours
Hours Minutes
C i-. L. % )K C.\
le at
(Kind of work done during most working life)
14 Industry
or Business.
15 Social Security No
c u iy
16 BIRTHPLACE (City).
(State or country)
<r- i. uy y
17 NAME OF
FATHER
2
7^ , / .
18 BIRTHPLACE OF
FATHER (City)
(State or country)
jSiU.
X.Xr.C.^.h,:.
19 MAIDEN NAM
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
21 Informant
( AHrlrpckl /I It
(Address) t) //
Jt Vu 'u^
I HEREBY CERTIFY that a satisfactory standard certificate of death
was tiled with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
: ' 2
(Ofii
cial Designation)
I:
(Date of Issue of Permit)
^ v 1/
A TRUE COPY ATTEST:
1 ■
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
'K? v
*** •••••
■■
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observancJ Q
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.
1953 PH
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 healthfv.lness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
R-301A
rRUCTIONS
FOR
L CERTIFICATE
1 giving
OF DEATH
not enter
e than one
e for each
, (b) and (c)
does not mean
de oj dying,
heart failure,
etc. It means
ase, or compli- ^
which caused
ions, if any,
gave rise to
cause (a),
; the under-
cause last.
ditions contrib- _
death but not
o the terminal
condition given
e:- Chapter 137,
>f 1954, requires
cians to print or
the cause or
i of death on
certificates, and
er 48, Acts of
requires Physi-
to print or type
under signature.
I9..tas>, to.^kAA
r last saw h«rf.alive on CL..V\.y. o-r.r\ ,.i9.
60-928145
V
Suffolk
(County)
...Wint.br.op
(City or Town)
ullf? (UnmmnmuFaltfj nf JftaaHarljuafttH
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 15
T2-.L. -tr- _ -t • f(If death occurred in a hospital or institution,
No ,1, .Q. J. U .dp . . . . rt . OXtl 0. St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
FULL NAME S.Qphla B.Q.SSmilSr. . jv?. Wafvfteran, n0
(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
(Usual place of abode)
Quincy, Mass,
(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
ll.J..Ck.y.\
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
19. .S
<09
have occurred on the date stated above, at ...A..‘St..'...-5?.€'.?.
, death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
A-Vy/oam V>e>S L
Due To
(b)
OL < Wc » C g C S
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
lYo.Y
, M. D
(Signed)
Vi • vb :
K PRINT OR tf£PE SIGNATURE)
(Address) \>J.\..V).V~V,i .•^'.L^r.iSA.CLSS. Date 19 V>j?.
6 Knights of Liberty, Woburn (Mont vale)
Place of Burial or Cremation (City or Town)
date of burial January. 2.9.., 19....6.3
FUNERAL DIRECTOR E j . . Z .• .Q.9.1..P^.9.U
address ^20 H.-rvard Street, Brookline.
281963 ■»
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED . j ,
or DIVORCEllO O OWed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of ..../ilexand..e.r....E.Q.s.en.au.er.
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE....^.V....Years Months Days
90
If under 24 hours
Hours Minutes
13 Occupation: Housemf e
(Kind of work done during most of working life)
14 Industry
or Business: .......
15 Social Security No UOnC-
16 BIRTHPLACE (Cit^US.Sia...
(State or country)
17 NAME OF
FATHER
Hyman Sansiper
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Anna Levine
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Russia
21 Informant Mi§S
(Address) 5 Co T.OU St . . Oil V
LncaL,
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)
ba......
s2JL
(Official Designation)
(Date of Issue of Permit)
J
j
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
JAN 2 81983 Hi
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.
H R-301A
rRUCTIONS
FOR
L CERTIFICATE
i giving
OF DEATH
not enter
e than one
e for each
, (b) and (c)
does not mean
de of dying,
heart failure,
etc. ft means
use, or compli- ^
which caused
ions, if any,
gave rise to
cause la) ,
' the under-
cause last.
ditions contrib-
death but not
to the terminal
condition given
- Chapter 137,
1954. requires
ans to print or
he cause or
of death on
ertificates, and
' 48. Acts of
equires Physi-
» print or type
rider signature.
». ^ •
1-6-59-925686
$ Suffolk
lu
J® (County)
\o Winthrop
QHir (CmttmmtuTraltlj nf HEasBar^uapIta
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
if DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
16
((If death occurred in a hospital or institution,
l give its NAME instead of street and number)
I u (City or Town)
\£ ■- yflower Cursing Home St
». -. (u. PHYSICIAN — IMPORTANT
iitilsil (Huse) oinith ((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)
10 Have Hay r^-e .
(a) Residence. No. St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 hof 3m u 27, If. Ad
(Month) (Day) '(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
AfaM.) 19.6s./...., to aJlyl. ... ...At. 19 M
I last saw ht IX alive on bj i 5. t , 19 k? . death is said to
have occurred on the date stated above, at .s^..'.ihO..../\.t m.
INTERVAL
BETWEEN
ONSET AND
^dea™
cUjS,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(_.CV€ dY4 { fr&hdyy nit <j
1
!bT Vf^f t) ^ 'r jj&.h. S. .1.0. >y
6 ij Yj.
\r
Due To
(c) - -
SIGmFICANT jP l A h&.fps. .. ,/f C.. //..!.. f n .>.
CONDITIONS
8 SEX
9 COLOR
Female
T/hit e
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED * iVnvr
or DIVORCED '••■u<ov'
10a If married, widowed, or divorced
HUSBAND of
_ . .(Give, maiden name of wife in full)
Benjamin D. Smith_
(Husband’s name in full)
(or) WIFE of
11 IF STILLBORN, enter that fact here.
12 75 6 2'
AGE Years Months '
..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Housewife
(Kind oi work done during most of working life)
14 Industry
or Business:
15 Social Security No.
K one
16 BIRTHPLACE (City)
(State or country)
Bos Lorr-
-Ma-ssT
Was autopsy performed? ../V...C
What test confirmed diagnosis? ^ «■•**/
S Was disease or injury in any way related to occupation of deceased
If so, specify .....
<Si““
. (PRINT OR TYPE SIGNATURE) , /
(Address) .\JJ J A/ 'JT.H. V.1Z. .. Date t j T' a
17 NAME OF
FATHER
George Huse
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Maine
19 MAIDEN NAME
OF MOTHER EllZ
our
6 JiTOp
Place of Burial or Cremation
DATE OF BURIAL
. 'in t Hr op
(City or Town)
J 2n. 29 19
7 NAME OF ni * pH ■ 1 *vrinl H c*
funeral director £?.
k’inthrop, Mass
20 BIRTHPLACE OF
...MOTHER (City) ....
(State or country)
Maine
21
William H Smith
(Address) "HSllT^Tlg T^T
ADDRESS
Received and filed
JAN 29 1963
(Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed .with me BEFORE the burial or transit permit was issued:
4 ./< It (tfPiC < 4J
nature 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 ■
l/r/rr
RULES OF ,
The fulfillment of the purpose of these* Iaw£ bans' theobservance 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 t<D all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
FORM R-301
1 for burial permit
oard of Health
its Agent.
iTRUCTIONS
FOR
tl CERTIFICATE
T OR TYPE
1 OR CAUSES
• DEATH
i not enter
re than one
se for each
), (b) and (c)
does not mean
ode of dying,
s heart failure,
i, etc. It means
ease, or compli- ^
which caused
ilions, if any,
k gave rise to
: cause (a),
i g the under-
cause last.
nditions contrib- .
o death but not
to the terminal
condition given
1-62-932382
{
®1|? (Emnmnnumtltlj of HHaBBarljUHBttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Suffolk
(County)
Winthrop
(City or Town) 'SXf CERTIFICATE OF DEATH Registered No
no Mayflower Nursing Home St. 1 give its NAME instead of 'street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME HOMCy Arthur. Cutting / (Was deceased a
,T, : J - ■>: •* -~;J ' J U. S. ”
t.i( so
(If deceased is a married, widowed or divorced woman, give also maiden name.)
War Veteran,
specify WAR)..
(a) Residence. No.. 5.2 Bellevue Avenue Winthrop.., .st.Mass..,.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of deatl^ years months days. In place of residence 3S^ars months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January.
(Month)
2£ 19..6.3
(Day) (Year)
4 I H EREBY CERTlF That I attended deceased from
19..^../ to..%/.U./JU sL6. , 19.£r~L
I last saw hj/ftalive on N/... ..., I9.tr. jf, death is said to
have occurred on the date stated above, at .... C/j..C/.j)r..m.
8 SEX
9 COLOR
10 SINGLE (write the .wordj
married married
WIDOWED ma"L c u
male
white
DIVORCED
UNKNOWN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due Tj
(b)
)QD....#.u&.'.tb..j?.A.L&.l !.^.*.&..£,Jl...
,7 ; D , r J $ -j-
Due To
(c)
SIGNIFICANT .4)..L£.&. S.fJ.^r...
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
T ~
4f**-
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? .U.
If so, spei
(Signature)
, M. D.
(Address)
, >
(^......'>X.<!..$...£..pfa
/ . /Print or /Type Name) /
i
Winthrop Cemetery Winth.r.Q.p.,.M.aRS .
Place of Burial or Cremation (City or Town)
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
1.14. lintffi.Q.y. .V/.in.thr.o.p..
Received and filed
JAN 29 1963
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorcedxjrg _• -p,_ j „ _
husband of
(Give maiden name of wife in full)
(Husband’s name in full)
(or) WIFE of..
12 If under 24 hours
AGE «c^earJ79.cMonths.l .^.Days 2y Hours Minutes
13 Usual
Occupation :
re
( Kina* oT work done during most working life)
d4# Industrv
Cambridge Fire heat.
15 Social Security No
16 birthplace (cityuinamh.ri dge.ig
(Stale or country)
as s .
17 NAME OF
father Charles Henry Cutting
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Charlestown
Mass-.
19 MAIDEN NAME
OF MOTHER
Fannie Coleman
20 BIRTHPLACE OF
mother (City) L.Qm.ori.dg.eT..
(State or country) v/iaS S •
hwkffaasSrace D. Cutting
'52° Bellevue Ave. Winthrop, Masi
(Ad
I HEREBY CERTIFY that a satisfactory standard certificate of death
"wascfiled withtne BEEORE the burial or transjt permit was issued:
*L.t.L..:.J...±wl y » A i
gent of Board of Health or other)
xu v
* ixU
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
i O'
.w V
— ; —
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice: . _ , ^ j u
(1) Attending physicians will certify lo^uch death's oriliy as those of persons
to whom they have given bedside 'durirtg aMafsl 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.
FORM R-301
i for burial permit
loard of Health
its Agent.
TRUCTIONS
FOR
.1 CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
■e than one
Be for each
. (b) and (c)
does not mean
?de of dying,
! heart failure,
, etc. It means
•ase, or compli- ^
which caused
lions, if any,
i gave rise to
cause (a),
g the under-
cause last.
» ditions contrib-
? death but not ^
to the terminal
condition given
-<>2-932382
a v A
| SUFFOLK
(County)
©Ijp nf HEaHaarfjufiettB
„ KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
)° Winthrop
I(j (City or Town)
\i No...Min.t.h.r.Qp .C..oi!mim.it.y.....H.Q.s.p..it.al St. ( give its NAME instead of *stre<
(City or Town making this return)
18
or institution,
street and number)
2 full name Jiuggi .er.o, .Baby Girl
(If deceasea is a married, widowea or divorced w
oman, give also maiden name.)
PHYSICIAN — IMPORTANT
no
(Was deceased a
U. S. War Veteran,
if so specify WAR)...
(a) Residence. No....?. 3.fc. . And r e w....Rd.. E, Boston St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
T/iaT
(Month)
3.1
(Day)
(Year)
That I attended deceased from
19.k.j£
4 I HEREBY CERTIFY
.../.-.A..0 , 19.. .JU. to ., ,....^...y
I last saw h£k!.alive on . 3lo _,.... .., 19 0.Aeath is said to
have occurred on the date stated above, at . ....m. I INTERVAL
BETWEEN
ONSET AND
DEATH
jJtAj
1 atteni
L r.i
19...
&!
ET CAL
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
F
white
DIVORCED
UNKNOWN
Single
1 1 If married, widowed, or divorced
HUSBAND of
DEATH WAS CAUSED BY: IMMEDIATE; CAUSE
<„ ANcxiA-
' Jv. i IV jj* (vl ? A ) B. If ( i .!/}
Due
(b) .
£rTo 'P/l£fwATUft|Ty
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? ... wi.
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?i
If so, specify
(Signature) .,
V'jA l u'/g'KiT'
- (Print or Type Name) .
(Address) .
Ul rtf'#*.
M. D.
9...bi.
6 Hoiu C<toa^ CejueteAxi Maiden
Place of Burial or Cremation ' (City or Town)
9d>» 2» 19
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
U'Lric.dnt Kaprino
ADDRESS 9 4to k., / W.
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
12
If. under 24 hours
.4:... Hours.... J?. Minutes
AGE Years
Months Days
13 Usual
none
(Kind of work done during most working life)
14 Industry
or Business:
15 Social Security No.
none.
16 BIRTHPLACE (City).
(State or country)
i MiriXktop , Ma d*i»
17 NAME OF
FATHER
tyod-eph. RpujfyieAO
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
tyo4.ep IvLne Pignato
& 04 ton
Ma&4w--
21 Informant tyot-eph R,nq^ieAo ( {cUhet)
(Address) .
2 <St. PndUceiv Pd. , [oa£ ^OdUon,Mann^
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
,.^..^.....kL.6r..'.?.r?.;L:..6^'.
(Signature of Agent of Board of Health or other)
..^.... .fri:...
(Official Designation)
(Date of Issue of Permit)
A TRUE COPY ATTEST:
■w
— -1 A
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY S
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
mErnw
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 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.
ORM R-301
d for burial permit
Soard of Health
its Agent.
RUCTIONS
FOR
. CERTIFICATE
t giving
OF DEATH
not enter
: than one
e for each
(b) and (c)
foes not mean
de of dying,
heart failure,
etc. ft means
ise, or compli-
which caused
ions, if any,
gave rise to
cause (a),
the under-
cause last.
ditions contrib- .
death but not
o the terminal
condition given
rS
te:- Chapter 137,
of 1954 requires
icians to print or
the cause or
ct of death on
l certificates, and
>ter 48, Acts of
, requires Physi-
l to print or type
c under signature.
irOcTf/'
11-61-931825
t
(County
%
(City or Town)
(Hljr (Enmmnnuu*altl| nf ilaBHartyuHFttfi
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
Registered No
^ „ f (If death occurred in a hospital or institution,
cf St. ( give its NAME instead of street and number)
COPY OF
CERTIFICATE OF DEATH
2 FULL NAME..^,:^%,/k __
(If deceased is a married, widowed or divorced
(a) Residence. No
(Usual place of abode)
tan, give also maiden name.)
PHYSICIAN — IMPORTANT
. J (Was deceased a
J U. S. War Veteran,
(.if so specify WAR
i0..z#.#:..£.. /&/*& SMafe st
dare of ahoHel J (If nonresident, give city or town and State)
....w!c..months..../^days. In place of residence years months days.
Length of stay: In place of death years.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
3
^ (Day) '(Year)
4 I HEREBY CERTIF Y>a That I attended deceased from
Gjg. 19 1 9j&£
I last saw h.-^r?ralive on .....^Jr&tjbfrm.. , 19. b* death is said to
have occurred on the da^^tated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
Due To
(c)
SH? M F ICA Ap...
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
3/7U4A
Was autopsy performed ?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceajfed?
If so, specify
(Signed)
C^T-' A /W>£r /ty £
"/ "d
M. D.
(Print or Type Name)
Zo S/i/LA-7z><?/t sP7- £ArrSosn^.
(Address^ /... ^ Date
Received and
FEB 4 1863
(Registrar of City or Town where deceased resided)
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR,
10 SINGLE (write the wt»rd)
MltKRIED
WIDOWED
DrrrmcED ,
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE
(Husband’s namc-Jn full)
-te
AGE^?.Y(
Months Days
If under 24 hours
Hours.. Minutes
13 Usual
Occupation :.
(Kind of work done during most working life)
14 Industry
or Business:
15 Social Security No...
i\
16 BIRTHPLACE (City).
(State or country)
17 NAME
FATHER
18 BIRTH PLACED]
FATHER (City).
(State or country)
19 MAIDEN NAME
OF MOTHER
ME /C
7 ~ /jl'V'jOj
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
21 Informant
i-fc.VV.-
1
I HEREBY CERTIFY that satisfactory standard certificate of death
was filgd with me BEFORE the burial qr transit permit was issued:
lign^tuce of. Agent of Board of Health or
r.cCCjr.J.. feV<. ...y
(Official Dcsignhtu
. Z^fck....k:. .J.y...
(Date of Issue of Permit)
A
Mi
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
> TO
i 1
'-{jh'
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of KO -4IS63 til
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 Cauae 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-305
V v.m
Ija
c -c £
•tJ .
tJ-—
'Sgd
U~u
» 0 S
y W!5
V ** '-'
•o u .
•a
£ 4> C
•£--c h
2 o u
3.* 0
U f-
Cjj -z
l yl
t-E v
o X
SSJi
u06 S
3 B.S
o E
ctfc =
t-=x
3 £-
u — _
8’i»
x5S
•Si go
f;o
* ux
~2 u
W*3 -
■c c*r
__x *
o ^ JJ
v-SrS
£ « £
E-Ss
u O <«
c £ c
5- B 8
6- 5 it
/
iu Es..a.ex
1“ (County)
.P..a.nv.e..r.s
(City or Town)
®Ije Commanfaealtl] of ^assacfiusetta
KEVIN H. WHITE
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
Danvers
(City or town making return)
Registered No.
retun
2
No P.a.n.V.e.r.jS S..t.a..t..e Hasp JLtja.l.# H.a.t.h.a.me. St. { (gJehs Se Inswap o? slrt^andnumbe?)
2 FULL NAME..
(a) Residence. No.
(Usual place of abode)
Mery. Ann ...Dp v is |{jwls War veteran,
deceased a
War Vetera...
(If deceased is a married, widowed or divorced woman, give also maiden name.) (.if so specify WAR)
Grovers Avenue /t. VMnthrop, Mass*
(If nonresident, give city or town and State)
Length of stay : In place of death....Q. years..2 months.. 3 days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
’death0!-- January 31, 1963
(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.)
Fracture Rt, Hip
Br..on.ch.Qp.n.e.umQnla
S Accident, suicide, or homicide (specify) .. accident.
Date and hour of injury . Oct.,. 31., 19.63
If accidental, was injury causally related to the death? . y.a.3...
W.In.thr..Q.p.* Ma.s.s..,.
(City or town and State)
Where did
Injury occur?
(City or town and State)
Did injury occur in or^bout home, on^rm, in industrial place, or in
public place ?
Manner of
Injury
Nature of
Injury
■.about home, on J^rm, in
Nursing Home
(Specify type of place)
Fell .to floor
(How did injury occur?)
as. .a.b..Q.Y.e.
While at work? Q.Q Was autopsy performed?
yes.
6 Was disease or injury in any way related to occupation of deceased flQ..
If so
artn
(Signed) Belph fAgver
(Address) _£fl5jb.fldy_j “ess.,.
Datfc/.. .!./..... 19.
M. D.
.6.1
7 ..St., J.Q..s..©.p.h.’..5. c.e.ma.t.ary..,. Eoxbury..
Place of Burial or Cremation. (City or^Town) ,
Februa ry S.j ,9 6;
DATE OF BURIAL
* FUNERAL DIRECTOR Rlchfl l?d C.„ KlrbV.,....I.I
ADDRESS B.a.S.t. BQC fon i'i
Received and filed
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
female
10 COLOR
11 CITIZEN
12 SINGLE B
white
OF U.S.
MARRIED □
WIDOWED □
YES □ NOD
DIVORCED □
UNKNOWN □
12a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
13 DATE OF BIRTH MQrch 28, 1876
AGE.8..6...Yearsl..Q.... Months....! Days
If under 24 hours
..Hours Minutes
IS Usual
Occupation :
Proof Reader
(Kind of work done during most of working life)
16 Industry
or Business:
17 Social Security No. J.Q.t P..e.t.erm.ine<l
Boston
18 BIRTHPLACE (City)
(State or country) Mass.
19 NAME OF
FATHER
20 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Joseph H. Davis
Iceland
21 MAIDEN NAME
OF MOTHER
-Mary Baker
22 BIRTHPLACE OF
MOTHER (City)
(State or country) I^flTpnd
wSSS! ■■-lg%5y6-e v^l§&ln
A TRUE COPY.
ATTEST : V
(Registrar of CityuJr Town where death occurred)
date filed Fabr.uE.ry. 6.., 19 .6.3.
(Registrar of City or Town where deceased resided)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE fc.. u3..'.U
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER «...
R-302
CO"
s g_j
2 3
u Sd
°« .
+- w
«•£ o
U «
C-eco
ti*
<T3
„ c a
C— CTJ
~c x
•o |U
V ^
^2 g
? , CO
u Ow
•o >»*o
«x
*2f
o ?
IS C
o'?
•Be©
u o ^
^Cx. (J
Zc*
■E ° o
_ *o
•O o o
1> ** c/5
u.« o
3H«
o *« ,,
« c_e
O «flX
*- V *-
X ja«*.
* *
•o .
t/1 — U
£§3
«*x-
a
u. c
2°g
So*
-.§ 2
a
o <**
oS£
X
E Plymouth
lw.
(County)
Jrockton
(City or Town)
No
®{jp (£nmmnmm?altl| nf fHafisar^uaeltH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Dr., ckton
(City or Town making this return)
2
COPY OF
CERTIFICATE OF DEATH Registered No
Veterans Administration Hemsitea&nh occurred in a hospital or institution
St- l give its NAME instead of street and number)
John. • owney /
2 FULL NAME I ^t\'as deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) J U. S. War Veteran
Lf so specify WAR,
. Boston
(a) Residence. No St... (Brlgpt on,) ^la as.
(Usual place of abodg q nQ £ nonrgident, 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
Jantiary 14f 1963
(Month)
(nay) m (Year)
4 I
TIFY
(Day) f
tHr ndyj^decease^^oi:
2Y py
FiraFSSiffi d„lh ,„d „
have occurred on the date stated above, at-r...*. <?.«?. TMih
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Acute myocardial infarct.
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? no
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
Leo \ aitzkin
M. D.
j
VA WSWPm 1
Brockton, Mass, 1/15/63
(Address) Date 19
Jinthrop Cemetery, vinthrop^toss,
J anuary ( 63
19
Place of Burial or Cremation
DATE OF BURIAL
7 NAME OF
ADDRESS
Received and filed
John rTchvby
ire. , Arlington* fSaa s *
FEB 15
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE (write the word)
MARRIED ,<4
WIDOWED **•»-•■* r-Lt.U
DIVORCED
UNKNOWN
hdsbmdI; "'"Thittsh"'!!. Grant
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 0/ 2 2D
AGE Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
(Kind of work done during most working jifej
14 Industry
or Business:
15 Social Security No..
lectri cal
16 BIRTHPLACE (City)...,
(Stale or country)
wsfc rfptrtvon
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) I*.
(State or country)
fe titi ett 8
John I . Downey
C'harlcgtot.n
asachusetts
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Catherine
ev?;re
Keough
Massachusetts
21 Informant
(Address)
VA hospital records
Droe^kton,^tfissachu3otts
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
Jan. 15 ,63
DATE FILED Z. lC
7
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING ..
ORGANIZATION AND OUTFIT
SERVICE NUMBER
April 2 8 ? 1919
Corporal
.Army
62 608
FEB 151963 AH
'ORM R-301
d for burial permit
ioard of Health
its Agent.
TRUCTIONS
FOR
l CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
e than one
se for each
, (b) and (c)
does not mean
ode of dying,
heart failure,
, etc. It means
•ase, or compli- p
which caused
lions, if any, I
' gave rise to I
cause (a), /
g the under- I
cause last. *
i dittoes contrib-
J death but not
to the terminal
condition given
,CL
-<>2-932382
0% CcrmauimuMltlf of MaaHarljUHfttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(a S.UfXolk.
(County)
\c \Tinthrop standard
L' (City or Town) CERTIFICATE OF DEATH Reg.stered No iSHSk.
no Winthrop ,C..omrEuni.ty.....H.Qs.p.it.al. St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Q.hS.pl©S /(Was deceased a 1
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran, l/f s /
specify WARjl.-iL.-TT
(a) Residence. No 2JL-HaWfckQaP»k AV©nU€ St . WinphFOP v •••■
(Usual place of abode) I (If nonresident, give city or town and State)
Length of stay : In place of death years months l.days. In place of residence^«^..years -months days.
m
i.,in.t.br.Q.p
(City or Town making this return)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
.£r&.
(Month)
2
(Day)
Jjl.. 5
(Year)
HEREBY C.ERTIFY, That I attended deceased .from
,2 ., to 19.
/, .. IT 1 1
I last saw h.//.’..klive on . .. JjfcjT., death is said to
have occurred on the date stated above, at a!— .m
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
k
a) ...Ss..±.Li £.yj...9..^3>ldl
£ dMyJZ....
VTT/T
Due To
(c)
OTHER g , . rv
SIGNIFICANT JMAtS..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
<sm-
j-y/u
Was autopsy performed? £$..
What test confirmed diagnosis? .......X-.X/..XX...X..
S Was disease or injury in any way related to occupation of deceased/*1!..!?
If so, specify
anrzc^Z )t^K
(Signature)
L!.Z!rA±lXZ: LL m. d.
&
(Print or Type Name) / .
(Address) Date 7-'X
a&fep /
Plavc of Burial or Crema
DATE OF BURIAL
-C//C: S'.
(City or Town)
bl
7 NAME OF .
FUNERAL DIRECTOR*-
ADDRESS
Received and filed
FEB 5 1863
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
11 If married, widoiyp!!) or divorced
HUSBAND of
(Give maiden name jj wife in full)
10 ^UN’OLK - (write the word)
MARRIED 1. .
WIDOWED J/J.j .
DIVORCED a
UNKNOWN
(or) WIFE of..
(Husband’s name in full)
12 57 7
iY..Sf;.Years....
AGE
ears —.Months Days
13 Usual
Occupation
{.a*: <E:
(K/nd of work done dt
If under 24 hours
Hours Minutes
during most working life)
15 Social Security No..
16 BIRTHPLACE (City)T
(State or country)
17 NAME
FATHE
THER (£ /5<£ )
18 BIRTHPLACE OF
FATHER (City)
(State or country)
<L...
19 MAIDEN NAME
OF MOTHER
£ . 7 k",
20 BIRTHPLACE OF "XX si v
MOTHER (City) ^.V..4.^...^fr.<..«C.,.
(State or country)
21 Informant
( Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was Abed with,fne BEFORE the burial or transit permit was issued:
JL
(Signature of Agent of Board of Health or other)
(Official Designa
IV
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
f 0
FEB -51963 Ffl
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 from disease un-
related to any form of injury.
(2) Board of Health physician* will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulnes's 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.
ORM R-301
for burial permit
>ard of Health
its Agent.
RUCTIONS
FOR
CERTIFICATE
?
OR TYPE
OR CAUSES
DEATH
not enter
: than one
e for each
(b) and (c)
loes not mean
ie of dying,
heart failure,
etc. It means
lie, or compli-
which caused
ions, if any,
gave rise to |
came (a),
the under- |
cause last.
ditions contrib- ,
death but not
o the terminal
.ondition given
62-932382
'a £
5 Suffolk ^ A
p (County) ^ , '
p Winthrop
f[j (City or Town)
<
s
Ulfj? (Eammcnutfaltlj of JSaoaarliujsttttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
23
STANDARD
CERTIFICATE OF DEATH Registered No
no }'iinthrpp Cmmunity Hospital s,. nam!?
2 FULL NAME..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
YSICIAN — II
.. ) (Was deceas
) U. S. War V
V i f so specify
deceased a
Veteran,
WAR)..
Length of stay: In place of death,.
PHYSICIAN — IMPORTANT
M.
Mass .
(If nonresident, give city or town and State)
years months/niL.days. In place of residencev^rlyears months days.
<„> Residence. No AvenUS St
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February..
(Month)
...5a
(Day)
1963
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Feb* 1, * , 19...63 , to-Feb* 5* *
I last saw hl..?ilive on .. Feb* f-0 ^63, death is said to
have occurred on the date stated above, at .'J...
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Coronary Thrcsnbosis
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Adenocarcinoma of Color
INTERVAL
BETWEEN
ONSET AND
DEATH
24 hrii # AGE ^ Xvars.. . Months r?'. "Allays
1 mon
Resection .of Bowel 1/31/63
irmed ? N.O
Was autopsy performed? 17 NAME OF
What test con ^rmed diagnosis ? Or .1.011 FATHER 5 /
5 W'as diseas?^r SjB^^lJ^^^a^rJ^atef^cfoccupation of deceased ?
If so, specify ..
EET
(Signature) -yfliv" - , M. D.
John F. Collins # M.D...
(Print or Type Name) . .
(Address) 2? Benningtm St* .Date... Fob.. 6> i9 . 63
L.a...t^.../v.
/It
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
%f.7AM..a Ju
ADDRESS
Received and filed
FEB 6
■<?r&
..19..
(Registrar)
tUk
1 11 If
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
fc/l , Tt
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED/^ tCloUje c(
UNKNOWN1"
married,
HUSBAND of
widowed, or divorced /p
A; Ck/i.a.jy:A7.3..
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
If under 24 hours
Hours Minutes
13 Usual /"T? 7- ' / / „ _ ,,
Occupation :.. A. .77 A f\..
; no
(Kind of work done during most working life)
14 Industry
or Business:
h 1 5 Social Security No ^D,,/ J2 -/A.-..//;, f A
16 BIRTHPLACE (City).
(State or country)
Z3..g.a..77<r..!Y.
/Ha ^ ->
18 BIRTHPLACE O:
FATHER (City)...
(State or country)
OF
6
e A/
l?>qce//a
■XZl/c,
19 MAIDEN NAME
OF MOTHER ^
ft /a/*
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
jr-T* A
21 Informant
(Address)
/ 3 7
‘fit'qTrtce C'Q./J.L/y.J..
~T $ / /*- 'Ret V r' e
/?<?J
I HEREBY CERTIFY that a satisfactory standard certificate of death
wa»i filed with me BEFORE the burial or transit permit was issued:
/ (Signature of Agent of Board of Health or other)
(Official Designation) (Date of Issue of Permit) ,
* X
A TRUE COPY ATTEST:
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 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.
FEB -GI953 Ffi
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.
3
permit
ilth
SUFFOLK
(County)
WINTHROP
(City or Town)
ULtyt Commontoealtf) of ifHatfgacljugett#
Bay View Nursing Home
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
(City or Town making this return)
24
Registered No.
No.
U Washington Avenue, Winthrop s,
JOHANNA GALLAGH3R physician - important
2 FULL NAME ° f (Was deceased a
(First Name) (Middle Name) (Last Name) I if so 'snldv^VVAR ) 110
(If deceased is a married, widowed or divorced woman, give also maiden name.) *• ^ y
31 Palmyra St., Winthrop
(a) Residence. No
(Usual place of abode)
4
..St.
Length of stay: In place of death.. ..years months days. In place of residence" V. ...years months days.
.28
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
00
t CO
3 DATE OF
DEATH ...
February
(Month)
..A*
(Day)
1963
(Year)
9 SEX
Female
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.)
.Arterips.cl.gx.ot..i.c heart disease,.
10 COLOR
White
11 SINGLE (write the word)
MARRIED yidowed
WIDOWED
DIVORCED
UNKNOWN
12 If married, widowed, or divorced
HUSBAND of ._
(Give maiden name of wife in full)
(or) wife of Dani.^X Gallagher
(Husband’s name in full)
5 Accident, suicide, or homicide (specify)
Date and hour of injury
IF ACCIDENTAL, was injury causally related to the death?
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or
public place ?
(Specify type of place)
Manner of
Injury
(How did injury occur?)
Nature of
Injury
Winthrop Cemetery Winthrop
lace of Burial, orXremation. (City or Town)
February 9 19.63
Place
DATE OF BURIAL
Informant
(Address)
alymr^Str; Winthrop
K FUNERAL DIRECTOR Arthur J, O.VMaley |
address winthrop Mass
Received and filed
FEB 7 1%3
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me^BEFORE the burial or transit permit was issued:
___ _____
» mcu WHO me ntrunr ine Dunai or transit permit was
/ (Signature of Agent of Board of Health or other)V
.19..
A TRUE COPY ATTEST:
(Registrar)
^^, 7 3
Official Designation) / (Date of Issue of Permit) w
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE ..LJ
RANK, RATING ..
ORGANIZATION AND OUTFIT
SERVICE NUMBER
: <07 i
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside
care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by
recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only
deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical
(drugs or poison) .thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting
from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those
of persons found dead.
FEB -71963 »‘H
following rules of practice:
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.”1 “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.)”
ORM R-301
for burial permit
ard of Health
ts Agent.
rRUCTIONS
FOR
L CERTIFICATE
7/
r OR TYPE
OR CAUSES
DEATH
not enter
e than one
e for each
, (b) and (c)
does not mean
de of dying,
heart failure,
etc. It means
3 se, or compli- .
which caused
ions, if any,
gave rise to
cause (a),
■ the under-
cause last.
ditions contrib- .
death but not
'o the terminal
:ondition given
b2-933UOU
i
5% (Eammnnuiraltli at HaftBarfyunrttfi
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
\ (County)
7/?.zA.£*
(City or Tofi-n) / — y — — -
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
25
Registered No.
2 FULL NAME... Ma Z7 A
(If deceased is a married, widowed or divorced woman, gi/^ also maiden name.)
. N JA. 7$ xj./y'a. Am. s ,..jt (.'Sal
...^...months days. In place of residence years
I (If. death occurred in a hospital or institution,
St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)..
(a) Residence
(Usual place of abode)
(City or town and State)
Length of stay: In place of death years
..months..
days.
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
1
(Month)
ZMZ
(Year)
4 I HEREBY CERTIFY That I attended deceased from
Q.&.y., 19....4.A..., to , V'£3
I last saw h4*xta£live on 'La**** SStf.
have occurred on the dateiafated above, at 4st...,.A
M/f/p HAlA
.., 19.Y-L?death is said
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
O vy ' f~ K btr.s’AS
.T*eVX..£..
Due To
(c)
A/ I dr
OTHER
SIGNIFICANT
CONDITIONS
NT (hP. . £.(k &A... A f Vi «?. .1/4.1
INTERVAL
BETWEEN
ONSET AND
OEATFJ
fo
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased
If so, specify
77
(Signature)
M. D.
' £m&IX A. Z.£A.*.£(At.&.
«a »..<rl
Place J\ Burial 01
Place
DATE OF BURIAL
tfjs
or Cremation
Md/ASAA
/ (City or Town)
77£ 7
FUNERAL DIRECT 7777777777^ 777777777}
ADDRESS
?SS 7/’Sf~~7>0 $7/?
Received and filed
FEB 8 1963
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCEJ
UNKNOV
7kT^XMMSW7772m7777777.,
( I.1UP maiflpn nama r\f n-ifn in Full \ ^
:n v ,
W /?/?/? /ts/
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in full)
12
AGE,
7k Years Months Days
ation GO* foe/*.
If under 24 hours
Hours Minutes
13 TJ sual * / » f rj y .
Occ upa t i 0 rvTrS. frlf. . S'S/... .
(Kind of work done during most of 1 working life)
14 Industry
or Busine!
(J S /v r/^ / X v.ic t f. Re f
15 Social Security No..
16 BIRTHPLACE (City)
17 NAME OF^N * /
FATHER /)/)///<? /
/A ✓
18 BIRTHPLACE OF
FATHER (City)
(State or country)
A- V/7/7 /
19 MAIDEN NAME/j
mother Art fit a
A
Tpa/aX !/
20 BIRTHPLACE OF 2
Is.SO
Aa/ /
MOTHER (City) XJ
(State or country)
7 <3 A/
21 Informa
(Addre
yd A? x/tf & fz/A /J AC 1 JT
I HEREBY CERTIFY that a satisfactory standard certificate of death
was hied with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Heaitb or other) ~ ~V<3 ^ ""
4./..A/.L3.
(Official Designation) (Date of Issue of Permit) . /
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE r r
FEO -8
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 t<p 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.
1963 Ffl
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.
ORM R-301
for burial permit
ard of Health
ta Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
3R CAUSES
DEATH
lot enter
than one
: for each
(b) and (c)
oes not mean
le o) dying,
heart failure,
etc. It means
se, or compli- ^
which caused
ons, if any, 1
gave rise to l
cause (a), r
the under- I
cause last. '
f itions contrib- ^
death but not
1 the terminal
ondition given
52-932382
(Summmtwraltli nf MaBHadjuaftta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
RTIFICATE OF DEATH
(City or Town making this return)
26
Registered No.
(If death occurred in a hospital or institution,
St.) give its NAME instead of street and number)
2 FULL NAM
CL/yf/. yr /yCs ^ S' ZZ? • PHYSICIAN — IMPORTANT
^ f (Was deceased a
w”Rl *
(a) Residence. No.....^. St
(Usual place of abode)
Length of stay: In place of death years monthsiTL...days. In place of residence.f~f. years..
(If nonresident, give city or town and State)
..months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF /.
DEATH /
i
Month)
ML
(Day)
(Year)
4 I HEREBY CERTIFY, TJiat 1 attended deceased from
Qh.rl.i wJL^-ijo .jh&A /..£! \9..k:.t
I last saw h..h'.KI!ve on j/™ I9,k...s, i
have occurred on the date stated above, at J^p.m.
, death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Due
(b)
Due To
(c)
SIG N?FICA NT*-
CONDITIONS + c-Cl ^
INTERVAL
BETWEEN
ONSET AND
DEATH
Y)Uy\fiy')
. ■
<7 id
Was autopsy performed?
What test confirmed diagnosis?
t
5 W'as disease or injury in any way related to occupation of deceased?
If so, specify
(Signature) -.p-.ffa.fr.
( S (Print or Type Name) ,
(Address) ^!.(,...s^....«..^...v.(<<?/!5v../7..v././(t.Cv.vcf:^'.Date..y.™..^r.y..^S 19,'Xms..
6 .nv.*w....u
Place of f urial or Cremation
DATE OF BURIAL
/a**-
ion _ * s? (City or I own)
-ftey ML M
Received and filed
FEB 12 1963
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
11 If married, widowed, or divorced
HUSBAND of
tfjffve
(or) WIFE of ...
(Husband’s name in full)
AGI
12 A3
- V/ A T ~ * U , *
ears.V^ Months Days
13 Usual
Occupation :
If under 24 hours
Hours Minutes
(Kind of work dode during most working life)
14 Industry
or Business:
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
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
TF* ^
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fil^d with me BEFORE the burial or transit permit was issued:
' ‘ ' ' jJU.
Agent of Board of Health or other)
filed with me BEy
/ . /Signature of
V7- '
(Official Designation)
Ul
(Date of Issue of Permit)
A
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
. ‘ J > A ) ^
I J-U.i.’- •
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, thoughrdteabled by hffc<£ogjnifced disease unrelated to any form pf
injury, have died wjtHoul recent medicaP 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.
1-301 A
TIONS
II
•RTIFICATE
ving
• DEATH
enter
an one
ir each
and (c)
r not mean
of dying,
irt failure,
. It means
or compli-
ch caused
, if any,
e rise to
isc (a),
e under-
i se last.
ns contrib-
ith but not
he terminal
lition given
hapter 137,
>4, requires
to print or
cause or
death on
ificates.
5 SVFFtJ-/?.
g (County)
1
(City or Town)
(Urnnmnmuraltlf of iHaHuarljUBrttfi
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
To be filed for burial permit
with Board of Health
or its Agent.
27
No.
CERTIFICATE OF DEATJty^ Ji>stered No
y iK -f ' fffrp'iiTT.'f Tifflfft 1 1 Srfi£.<iirSK»
2 FULL NAME.
£. Q.A.k.£.AlAA.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No..<£y?. L„
(Usual place of Abode)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR).
(If nonresident, give city or town and State)
Length of stay: In place of death years months./C'^'days. In place of residenca*^Lj£”years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
(Month)
(Day)
Jfl2>
(Year)
4 I HEREBY CERTIFY,
//cJ l9.ir.2L,
I last saw hfcY.alive on
That I attended deceased from
have occurred on the date stated above, at
£2L, jo Li*
OLPr.._.// , 19 A3 , death is said to
4 / ‘fs' A ' «
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
./irlerr/oiscle.
o 7 1 A r/e y icAcl^r.^s
Due To
(c)
OTHER ~T\ •
SIGNIFICANT Ml
CONDITIONS
-.MdMvy
INTERVAL
BETWEEN
ONSET AND
DEATH
¥<vk$
SI
Ts
/o
iYS
Was autopsy performed?
What test confirmed diagnosis? /
(Signed)
(Address)
5 Was disease or injury in any way related to occupation of deceased ?
If so, spyify,-.,....^ Cifrf fo -
Lu. M. D.
iHtSS ...D^t&2(./.7^y/..i9
&
. Ar BJP.AAG A JitilfL KASS.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL £ A T /9 /.A/. - 19^ 3
FUNERAL DIRECTOR /Y .MlL
ADDRESS . iC /'‘,r/y/Pe£ _ _
FEB 131963
(Registrar)
Received and filed
.. 19-
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED Xj'M/}//'
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
13
AGEJ u ..Years Months..- Days
If under 24 hours
Hours Minutes
Ckcupatio,, ,.
(Kind of work done during most of working life)
14 Industry
or Business:
r..£
15 Social Security No —
16 BIRTHPLACE (City).
(State or country) _
17 NAME OF
FATHER /Vf^
18 BIRTHPLACE OF
FATHER (City)... //?.£AA/y..£...
(State or country)
19 MAIDEN NAME
OF MOTHER
Q
20 BIRTHPLACE OF
MOTHER (City)
( State or country)
/SfeZ/f/V/J
21
Informant
(Address) 9 j^/A/r
I HEREBY’ CERTIFY' that a satisfactory standard certificate of death
was filed with me ^BEFORE the hurial or transit permit was issued:
£■> ■ - _
(SiynaUirc of 'Agent of Board of Health or other)
(Official Designation I (Date of Issue of Permit) - v
’ 7m, n. * 1/
EXTRACTS
FROM THE LAWS OF THE - - _
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
i L /.,
A physician or registered hospital medical officer shall forthwith, after the .
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death., stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one, where -same wa6
contracted, the duration of his last illness, when last seen alive by tfierprhydiciah-
or officer and the date of his death. . .Gen. Laws, Chap. 46, Sec, 9. * (
' /'/ - ^
A physician or officer furnishing a certificate of death as required/ by the
preceding section or by section forty-five of chapter one hundred" and four-
te n, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifyingrtherwaf. and
shall also certify in such certificate both the primary and the secondary. imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law, or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
-.that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
c^use of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
• p: L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
: of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. — General
L'aws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is ml such board, from the clerk of the town where the body is to be buried
mr “ e funeral is to be held, or from a person appointed to have the care of the
itry or burial ground in which the interment is made.
. Chafi. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
eerson engaged in domestic service for wages, however, designate the occupation
y the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT..
SERVICE NUMBER
ORM R-301
for burial permit
ard of Health
ts Agent.
RUCTIONS
FOR
. CERTIFICATE
OR TYPE
OR CAUSES
DEATH
not enter
: than one
e for each
(b) and (c)
ioes not mean
ie oj dying,
heart failure,
etc. It means
ire, or compli- ^
which caused
ions, i) any,
gave rise to
cause (a),
the under-
cause last.
ditions contrib-
death but not
o the terminal
:ondition given
<>2-932382
(is
IQ I l( County)
((County)
\o LJ^Zkru
Ltl.
wn)
([ j (City or Town)
\<
leu No.
(HflitnttBttuttaltfy of fMaaaarliufitfttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No SB
/ Q f? A / r/Li death occurred in a hospital or institution,
/.. .T^. St. | give its NAME instead of street and number)
222 *JAcoa pA o-lck. _qr
(If deceased is a married, widowed or divorced woman, give also maiden name.) J U. S.
yif so s
(a) Residence. No J......./... St..
(Usual place of abode) » ,
2 FULL
PHYSICIAN — IMPORTANT
/as deceased a
. War Vetera
specify WAR)
War Veteran, r )
Y
Length of stay: In place of death "..years months days. In place of residence....?... .years months days.
T...ye
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
jhsu.
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
19 to 19
I last saw h alive on 1^. death is said to
have occurred on the date stated above, at /a...LLdan.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due
(b)
Due T^jue /c VvR-/tcyct/ («au3<33 p T <? St
fc) J.... .I......
(X fl-W r € — g (? < C / tt s'rvn — tnv
M i , U
signtficantOVI, hll.iox.bl Yh&£/.‘..£&/
CONDITIONS^ , /U I
INTERVAL
BETWEEN
ONSET AND
DEATH
iA
1
rviCib/
S-tr
1
recoup
W'as autopsy jVtfloTi
What test confirmed diagnosif
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature) _ , M. D.
<*MA£iJ£S .....U-A-AmA./)/...
(Address) Vi//Af...^jy^^.^r^>*..°^^^^^^1Date..(j!ty//.jiI.^....19.4()i.^
6 £k£jft..K....i I
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .. £jL& 1.7. 19.4.3.
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
£1 lu >k
FEB 18 1S63IZZ..I
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
<AAa t
9 COLOR
lUU '
h
10 SINGLE (write the word)
MARRIED
WIDOWED, -
DIVORCED^-’ 0^(11 X'2)
UNKNOWN
11 If married, widowed
HUSBAND of
(or) WIFE of..
/ed.Atf divorced /I
...&A..<ZAU
(Give maiden name of wife in full)
(Husband’s name in full)
AGE
Sh-
ears Months Days
If under 24 hours
Hours Minutes
13 Usual /O / CTs? jc-
Occ upa t ion : . ~r. ~ . . f .)
(Kind of work done during most working life)
ML"dE ’3m-...££.TAt..c, Eaa.DS
15 Social Security No.. .<£ 3 V -eQ..- A
16 ?^L£Ui‘1>' :dAA-fQ-ev *
17 NAME OF
FATHER
FWiD /U»cce^
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
uSS-Ltd...
21 Informant
(Address)
Sar ah....M±^.A.
(Official Designation)
k p. p H
(Date of Issue of Permit)
'f V
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
19 MAIDEN NAME
OF MOTHER
/h £$51 e M>Ll (oY)
/ f CoflAL j/J ( /- ip
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the Jjurial or transit permit was issued:
n - (&\
/ ^Signature of Agent of Board of Health or other)
Y^.t.Y./...±...,.Zr/.d
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
servicf: nttmrf.r
FEB 18:^63 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 Cauae 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.
(Hornmnnuifaltli of fHaasarfjuarttfi
Suf f olk
(County)
(U,
\o
iln.thir.oj)..
(City or Tow
(City or Town)
No,
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
oc
Rnhort Owa-n Ri „ ((If death occurred in a hospital or institution,
Vr-- .0 naru. S St. \ give its NAME instead of street and number)
2 full NAME 2.4 .Quine dy„_ Avenue
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
(Was deceased
\ U. S. War Vete
\if so specify W
eteran,
AR)..
NO,
(a) Residence. No 2.4 Mns4y.....AY.eme. st
(Usual place of abode) i (If nonresident, give city or town and State)
Length of stay: In place of death years^T^^onths days. In place of residence.,33 ears months days.
MEDICAL CERTIFICATE OF DEATH
dea?huf. Z.e..fc.ruary 1.6. 1965
(Month) (Day) (Year)
4 I HERE I? Y CERTIFY, That I attended deceased from
to F£B£..uA!Z>.y...i<*. i9..&£....
I last saw h/Arjalive on Fg 8 fcu/ifi.y. (F , i9.4.i, death is said to
have occurred on the date stated above, at JH. .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a ) ACtfSI.C ..CSKF.
(b) A a. ir£/2./0.£.QA> FA^a.s/.s..
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? /y'.<p...
What test confirmed diagnosis?
5 W'as disease or injury in any way related to occupation of deceased? ~Ab I
If so, specify
(Signature;
^.O/CCV’M.U G,.A.£.n&..U.
' (Print or Type Name)
... M. D.
6 Wlnthrop Cemetery , Winthrop
Place of Burial or Cremation (City or Town)
DATE OF UURlAL^lfabl
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
.4 g ^.Winthrop.
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
single
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE.85-Y ears 1 Months... 2? 4-Pays
If under 24 hours
Hours Minutes
&.ion^etired) Bldg.Supt ..
(Kind o! work done during most \v<
orking life)
14 ordBl7neQO.miiie.r.ci.al....apartments
15 Social Security No.. C10» 07) - / 7 93
16 BIRTHPLACE (City).
(State or country)
England
17 NAME OF
FATHER
Edward Richards
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Engl and
1 argaret done;
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
W A
’ 1 Cv
la;
Informant Alfred Q.. Richards
(Address)
24 Quincgy Ave, Winthrop
HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
- ; t.i-t — -
(Signature of Agent of Board of Health or other)
r+i? )
5^.7. .. .SVr.L...tC. . . V* . L, . S1.L1. tu.
(Official Designation) (Date of Issue of Permit)
rjH
h
w
A
V
1 A
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE....
DATE OF DISCHARGE
‘■vv i
RANK, RATING ....
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RUL
m
-
o fit4.
j-
OF FRACTICE
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 from disease un-
related to any form ofinjury.
(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.
ORM R-301
for burial permit
ard of Health
ts Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
lot enter
than one
! for each
(b) and (c)
'oes not mean
ie o) dying,
heart failure,
etc. It means
se, or compli- p
which caused
Ions, ij any,
gave rise to
cause (a),
the under-
cause last.
litions contrib- -
death but not
o the terminal
ondition given
62-932382
Suffolk
(County)
l U.
ic Winthrpp
(City or Town)
<
©fjp Ghimmflttumiltlf nf HlaiaBadjUHtfttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
30.
2 FULL NAME-
STANDARD
CERTIFICATE OF DEATH stered No.
1 n Qnyf Q) ri ps iirp „ 3 nt,hT>nn {Of death occurred in a hospital or institution
No Jr..y. .l^UpIirpp St. | give its NAME instead of street and number;
PHYSICIAN — IMPORTANT
MARY M/MA (Armstrong) TAYLOR
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
f so specify WAR)..
(a) Residence. No IQ Surfsi.de Avenue s,.....Y.i.n.t.U.r.Qp.„...
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death. A.Qyears.
..months days. In place of residencAr.O... years months days.
MEDICAL CERTIFICATE OF DEATH
DEATH* .... ....FEBRUARY 1.6..., 19.6.3..
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
19 to 19
I last saw h alive on 19 death is said to
have occurred on the date stated above, at 3&- jl-m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Y)'-g-crf4v a/;rg -f- g ^-r Arrg-r"
(b)e...^..«,a..5-g-S 7 .p..Y.£_S:.^..^..^..A/y dkuL
Due
(c)
Ifr.a A..T.l£.Y..!!.u....?..?../e..Y.t’/fc..c. J\£.u£...
OTHER
SIGNIFIC
CONDITIONS
aLt
Was autopsy performed? .
What test confirmed diagnosis?
X'
INTERVAL
BETWEEN
ONSET AND
DEATH
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ..y^.\
sOLj. —
(Signature)
3-4^-
A.ifLYAY m. d.
JxlE. JmEIlA'Z. ”
..£L.aA.KA..ifc...JS>.
, (Print or Type Name) / J
(Address) ,|rU...f.l<...r.kY..0..|3y.li^U..SS-Date....Y.y./...7./.....19..4?^
6 Hq1x.....Gt.q.s.s
Malden
Place of fiurial or Cremation
(City or Town)
DATE OF BURIAL
..February. 19„»„
...62.
7 FUNERAL DIRECTOR ZR.,.lNK....H..» .C.fRR
a ddr ess ?..9 ...S.t»...t...».GJiarl.e.sLow.n-
Received and filed
FEB 18 1963
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
SEX
F
9 COLOR
White
(write the word)
10 SINGLE
MARRIED __
widowed Married
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of FRMK....L* TAYLOR
(Husband’s name in full)
12 qp
AGE T..~... Years Months Days
Housewdas*?*'
If under 24 hours
Hours Minutes
13 Usual
Occupation:
(Kind of work done during most working life)
14 Industry
or Business:
At Horae
15 Social Security No..
16 BIRTHPLACE (City)
(State or country)
ova
er „
Scotia
17 NAME OF
FATHER
Robert Armstrong
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
unknown
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Nova Ront.ifl
21 Informant Mr.s..f. ...Ls t her Sanborn
(Address)
32 Francis St., Belmont
iL
I HEREBY CERTIFY that a satisfactory standard certificate of death
was 6|ed with me BEFORE the burial or transit permit was issued:
/CsJLjeJto ,y
(Signature of Agent of Board of Health or other)
. .^.:..Y’.. A A^...A.^..!^.....A
(Official Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
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 df th*
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.
'18(963 M
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation 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.
ORM R-301
for burial permit
>ard of Health
ts Agent.
ntUCTIONS
FOR
L CERTIFICATE
' OR TYPE
OR CAUSES
DEATH
not enter
t than one
e for each
, (b) and (c)
does not mean
4e of dying,
heart failure,
etc. It means
ase, or compli-
which caused
’■ions, if any,
gave rise to
cause (a),
; the under-
cause last.
ditions contrib-
death but not
to the terminal
condition given
62-933UOU
\1s.M.fz£&.L &
(County)
(City or Town)
Qlfje (HmnmmtuiFaltlj of fUaaBarijuafttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
31
Registered No.
death -°-cc---ed ,n a -hospi,al or institution
2 FULL NAME .
I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
.^EA/.A. J.JAAj.
(If deceased is a married, widowefypr divorced woman, give also maiden name.)
■ J (W'as de
) U. S. W
(if so spe
deceased a
War Veteran, , ,
specify WARI...<XiSrL.
(a) Residence
. ko&2L£M#£<SM£.. dt£. s,...^../d/..^..//.<f/./?.
(Usual place of abode)
(City or town and State)
Length of stay: In place of death years... ./..months days. In place of residence^fcayears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
(Month)
LSL
(Day)
(Year)
4 I HEREBY CE.RTIF Y That I attended deceased £rom
.pJ .QrrQ.-. 19 .6 2^ to LlJ Vlp3
I last saw hfc^^live on , 1^4^, death is said to
have occurred on the date stated above, at if.hL.f)..
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
TrzJLcuAL. l.'L^fz.TrXZZ.
p i XEA/lEXMAA’... fc ^
CONDITIONS
Was autopsy performed ?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased urn
If so, speetfy
(Signature^
M. D.
(Address).
sr/ttmi£d,£. y~ a /A>r>,
Place of Burial or Cremation (City or Town)
DATE OF BURIAL AM. AL.O. 19^.3.
FUNERAL DIRECTOR N..A.D.. A-AEK I/A. (X. ' 1.(1 B>
ADDRESS IX TH/l? 0. /3.
Received and filed
FEB 19 1963
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
^ ' -// r A
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED ,y , ,, / „
UNKNOWN *6 /O OeO'l
11 If married, widowed, or divorced
HUSBAND of
_ (Give maiden. name of wife in full)
(or) wife oiX.XA.ACXA.J.A.J.. Z..X.A.4./../Z.AAZ.
(Husband’s name in full)
12
AGE / /Years Months Days
If under 24 hours
Hours Minutes
Occupation :..El/A..<X..IX. /X.A./X.A'.A^,
(Kind of work done during most ofiworking life)
14 Industry
or Business: /y/y T cc.
15 Social Security No Al./.l.f/^z.
16 BIRTHPLACE (City) / E£Jz:./4 /.V. O ....
(State or country)
17 NAME OF
in c\i>i r, ur ^
FATH ER s/V ,-/ /y J’ C /L ++* , « ,y /A, /rr,x
18 BIRTHPLACE OF
FATHER (City) L.IX.A.AA.X...L>...
(State or country)
19 MAIDEN NAME .
OF MOTHER ( V* ///l 0 jA Af I
20 BIRTHPLACE OF , a> ^ / v .
MOTHER (City) 'A.A.A.A.A.A..-..
(State or country)
2 1 Informant A.M.Zf.M. t lX. AA/AX'1.
(Address) AtA.XXmAA.iEAX..
A TRUE COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed, with me BEFORE the burial or transit permit was issued:
itlr... -1.. ‘‘rjH.lr. V. . V . . X.. L.. .c. L-, JCL. ..rrk. . . 2.V4. r. — y.- -...
(Signature of Agent of Board of Health or other) ' ^ J
.../.AAA.., J
(Official Designation) (Date of Isaue of Permit)
•vp. i 7Zl in W X V
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF FRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths onjy,as those of person^
to whom they have given bedside care during a last illness from disease *in-
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-301
for burial permit
ard of Health
ts Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
3R CAUSES
DEATH
lot enter
than one
for each
(b) and (c)
oes not mean
!e of dying,
heart failure,
etc. It means
se, or compli- ^
which caused
ons, if any,
gave rise to |
cause (a),
the under- I
cause last.
Htions conlrib-
death but not
j the terminal
ondition given
•2-932382
ullj? (SmmnmmiFaltfj nf mJaasadjufiFtta
T
..Suffolk
(County)
Winthrop
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
(City-orTown) CERTIFICATE OF DEATH
No Winthrop Community Hospital
(City or Town making this return)
32
Registered No.
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Elizabeth MoGluskey (Dunnigan).,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
..) (Was decea:
) U. S. War 3
V • f so specify
deceased a
Veteran,
war) no
<„ No 18 James Ave„ Winthrop Mass Si
(Osual place of abode)
Length of stay: In place of death years months..l6^ays. In place of residence?:?.?....years months days
At
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 date of February 18 19.63..
DEATH
(Month)
(Day)
(Year)
4 I HE REBY CERTIFY, That I attended deceased from
4..&..VV* 19..k..Xr..., to /..TT. 19.£j..3.
I last saw htjtfalive on ^..<d..t>. „....i..S:i. I9....(t.3death is said to
have occurred on the date stated above, at .76 . /0 /F m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
tvw/f A yIpy1'
« U L b e,
g-
Due fo
(b)
U.eAif
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? .....y»...w -
What test confirmed diagnosis? £l..l..vv..t...e..<i..l
INTERVAL
BETWEEN
ONSET AND
DEATH
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature) ! , M. D.
L.\.3±ljZma^
■ ,1, . I (Print or Type Name) 1 j .
(Address)vA<..li..l^..F:.I\Y..l3 ^?...,.../Vl..^t.$-S>...Date....«?ryc./.^. ^...19.B^.Tj
6 St. : Tat rick's 1 owe 11
Place Xm iiuT&i 01 v^iemation (City or Town)
Feb. PI ,/3
DATE OF BURIAL
7 FUNERAL DIRECTOR Maurice, Kirby
address Win throp...
Received and filed
FEB19196T
(Registrar)
8 SEX
F emal e
PERSONAL AND ’STATISTICAL PARTICULARS
9 COLOR
Vh i t e
10 SINGLE (write the word)
MARRIED _ T
widowed Widowed
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Frank A. Mcduskey
(Husoand’s name in full)
AGeF* l .Y
ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:.. JJoineStlC
(Kind of work done during most working life)
14 Industry
or Business:
15 Social Security
I
i6 birthplace (City ) . N o r t h Chelmsford
(State or country) Ma S S .
17 NAME OF
FATHER
Francis Dunnifran
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
of mother Mary McArdle
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Ireland
21 Informant Mary McCluskey
(Address)
IP James Ave., Vinthro^
A TRUE COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
zX^trr:LjfSrdL. r.s/..L.. J
I (Signature of Agent of Board of Health or other) ( /v-o )
ULilti 0:LK J
(Official Designation) (Date of Issue of Permit) S
A
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT .U.S.Nayy,
SER VI CE 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.
fe:
•3 1,
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been 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.
US Suffolk
)a (County)
A* wzurtnrop
\°
iw
fu
<
l j
®fj? (£mnmnmu?altff nf fHasaarljUiartta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
,34
Registered No.
(City or Town)
Ivy t-To oVvi v.rr+ „ ((If death occurred in a hospital or institution,
No l St. ( give its NAME instead of street and number)
2 FULL NAME
Jennie S.R oilman
(If deceased is a married, widowed or divorced woman, give also maiden name.)
, , _ M 47 Washington Avenue
(Usual place of abode)
PHYSICIAN — IMPORTANT
as deceased a
War Veteran,
specify WAR)
.. j (Was
)U. S.
(.if so
(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
jEEEI.
(Month)
Aik,..
(Day)
../.9A.S.
(V ear)
4 I HEREBY CERTIFY, That I attended deceased from
19 to 19
I last saw h alive on 19......... death is said to
have occurred on the date stated above, at /. i m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) U
Due
(b) .
Ao.
TV\ CL f'UOf 0. 1 C-Iaa. S €. S p
Q. LI f (J (- O v C to a. v
Due
(c) c
OTHER 1 - I y r
SIGNIFICANT
CONDITIONS v
Was autopsy performs
What test confirmed diagnosis?
C «ic YW 8 (V l U ST
INTERVAL
BETWEEN
ONSET AND
DEATH
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
ly ,, -J; .f..y
M A
6 .7.P.resi...Hi.lls....Cren^tor.y., Boston,
Place of Burial or Cremation ' (City or Town)
DATE OF BURIAL .l.ebrUO £X....?:5»....19..6.3..
7 funeral director ,B.snj.2niin....E.«.S.Qlonioii
address 2+20 -TriTV"rd Street^ Brookline
FEB 25 1963
Received and filed
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
tfiemale
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED
divorced naruied
UNKNOWN 1 - -Leu
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Abrsh^....Eoitffian
(Husband's name in full)
AG gAV ...Years..
..Months Days
If under 24 hours
Hours Minutes
13 Usual
occupation : Phy.ci.clan. (retired)
(Kind of work done during most working life)
14 Industry
or Business:
15 Social Security No..
16 BIRTHPLACE (City).
(Stale or country)
Tatvic
17 NAME OF
FATHER
Ahrahsm Segal
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER Vreda
(unknown)
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
21 informant .Ab?.:.h.5®....B.Qitman.
(Address)
47 Washington Avenue, Winthrop, T'ass
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
d
'■ (Signature of Agent of Board of Health or other)
1.
(Official Designation) (Date of Issue of Permit) -
1 ^
A TRUE COPY ATTEST:
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 oThe text goes on. The rest is in the file.