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Town Clerk, Winthrop · from the Internet Archive · 502 pages · 32.0 MB
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FORM R.301
led for burial permit
Board of Health
jr ita Agent.
NSTRUCTIONS
FOR
CAL CERTIFICATE
I
NT OR TYPE
IE OR CAUSES
>F DEATH
lo not enter
lore than one
tuse for each
a), (b) and (c)
j does not mean
mode of dying,
as heart failure,
i ia, etc. It means
isease, or compli-
s which caused
ditions, if any, j
ch gave rise to I
ve cause (a), }
ing the under- l
■g cause last. J
onditions contrib-
to death but not
i to the terminal
t condition given
).
2-62-932382
X
Suffolk
(County)
Winthrop
(City or Town)
No1
(Cmttmmmipaltlj at
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
,lr..A/±vc
(City or Town making this return)
Registered No.
2 FULL NAME..
Winthrop Community Hospital c- KIf death occurred in a hospital or institution,
1 * * St. ) give its NAME instead of street and number)
„ , _ . PHYSICIAN — IMPORTANT
Sarah L. Bird
(If deceased is a married, widowed or divorced woman, give also maiden name.)
. J (Was deceased a
| U. S. War Veteran,
vif so specify WAR)..
(a) Residence. No ^jtPne St St B OS t Oil j M&SS •
(Usual place of abode)
JLO
Length of stay: In place of death years monthsdr..^...days. In place of residence.. i/'.H?.years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 WATE OF AJ- ***
DEATH
(Month)
...ffe lci\f.
(Day) (Year;
4 I H E R_ E BY CERTIFY, That 1 attended deceased from
JA N * , I'dfcP yLtfkM. *4. I9..felf.
I last saw tr-LTalive on .... \J „fV death is said to
have occurred on the date stated above, at ...
8 SEX
9 COLOR
Female
White
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Jl? ? laXiUiQ
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis? ..
INTERVAL
BETWEEN
ONSET AND
DEATH
u
% day*
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED . ,
unknown — in? is
HUSBAND of ..
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in full)
12 99 . 3 1
AGE \ ears...-: Months. ,~T. D ax's
If under 24 hours
Hours Minutes
13 Usual
Occupation : $C .!lQ.Ol „ Tg. d,Ch§X.
(Kind of work done during most working life)
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ....J
(Signature)
’rutt or Type Name)
_M. D.
, - v-w,
6 &ural C©ii«3ter»- Kes* .Bedford
Place of Burial or Cremation (City or Town)
...Jan. 6 ,g6A
DATE OF BURIAL
FUNERAL DIRECTOR I I ^ '. ,C-
V/inthrop, Mass.
= JAN ii 1964 =
ADDRESS
Received and filed
(Registrar)
14 o^Sess: M^SChOOl
15 Social Security No....f.V.P.^^..
16 BIRTHPLACE (City) ^XiCL~e.mts;.r.
(State or country) i c. J f. m
17 NAME OF. #
father ill L E E ird
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Eliza Tobey
20 BIRTHPLACE OF , r,
MOTH ER (City) .t A® 1 ?.. . .? .?. 9. .1 .4. .
(State or country) Lia S S
21 Informant Irir.tV:.!.. .A:.-... .-'.ill
(Address)
north Conway Mew Hampshire
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with ipe BEFORE the burial or transit permit was issued:
^ iSJ,
/ @ ^Signature jaf Agent of Board of HeAlth or other)
(Official Designation) " (Date of issue of PernijyO
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
-
• :r.n "vv-
^ % l
y t
•y/f
RULES
.■ , iiiMW" v\;
imv--
The fulfillment of the purpose of these
following rules of practice: 1 AM ± c_ iviKti p ||
(1) Attending physicians will ccHniji to sdgH dMtns 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.
Jaws c^l* the observance of the
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
led for burial permit
Board of Health
>r it* Agent.
4STRUCTI0NS
FOR S
:al certificate >
VT OR TYPE
E OR CAUSES
F DEATH
o not enter
5 re than one
use for each
i), (b) and (c)
V.
5i
h
does not mean
•tode o) dying,
is heart failure,
a, etc. It means
tease, or compli-
which caused
litions, if any,
h gave rise to
\e cause (a),
ng the under-
: cause last.
inditions contrib-
S
[to death but not
to the terminal ^
condition given
$
*
vj
>4
•62-932382
Suffolk
(County)
p Winthrop, Mass
(City or Town)
©fjr (Enmmomu^altli of MaHHar^uoflta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
2
2 FULL NAME
N Winthrop Community Hospital
Daniel Lyons
((If death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
deceased a
War Vetera
specify WAR)
YSICIAN -
(Was de
J U. S. W
V i f so spe>
ar Veteraji, ylftf
117 Shore Drive
(a) Residence. No - St X Z...
(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.xiLyears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
J.AK.
(Month)
LZ&SL
(Day)
(Year)
I H/E REBY CERTIFY, 'Ufiat I attended
y/v
I last saw h//^live on 3
have occurred on the date stated above, at m.
deceased from
iM...
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
Due To
(c)
SIGNIFICANT .rrr..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis? ....... Jr..
5 Was disease or injury in any way related to occupation of deceased jfr. Q
If so, specify
(Signature)
(Address)
M. D.
ih..y.mb.M aL ja...j.m...cRAAl.^..
'A M
6 ..
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 FUNERAL DIRECTOR A.LAA..Rl.ClZ. XA... ...
.2 / e I A '
ADDRESS ./4,..././S, '£.ty.j($..6?/?..
Received and filed
■ IAM.fi IUb4
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED n , . .
DIVORCED \j ///&/■ Z
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE
l.*Z
ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
xf Z"
(Kind of work done during most working life)
14 Industry
SL~-/r 4 . KMC'/l'cr
15 Social Security No
16 BIRTHPLACE (City).. -&7TTT77-
(State or country) 3
17 NAME OF
FATHER A'/ /£// A- S/- 7 Z Y 6 A/S
18 BIRTHPLACE OF -a , ^
FATHER (City) PA.±AA..^....
(State or country)
M*SS
19 MAIDEN NAME
OF MOTHER C 4
C 40 $
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Qgs r a at
i 1 Rss.
21 Informant
(Address)
M'SS- &M/IV A..y.A..:Y..A.
/// S t/t/p/? /a/P/pa ^/rvr//v/A/^
I HEREBY CERTIFY that a satisfactory standard certificate of death
wjts filed with me BEFORBYhe burial or transit permit was issued:
A, scd±:A±^:r^.AJ...
j ’ (Signature of .Agent of Board ofj Health or other) , /
7^7.
|) ’ 1/
(Official Designation
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.;..;.~...:..;..
DATE OF DISCHARGE.
T r’i-'
RANK, RATING
ORGANIZATION AND OUTFIT
inF'i jr\
SERVICE NUMBER
......
RULI
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.
VI R-301 A
TRUCTIONS
FOR
L CERTIFICATE
i 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
ise, or compli- ^
which caused
ions, if any,
gave rise to
cause (a),
the under-
cause last.
iitions contrib- ^
death but not
o the terminal
ondition given
Chapter 137,
19S4, requires
ins to print or
le cause or
of death on
[rtificates, and
48, Acts of
iquires Physi-
print or type
der signature.
6-59-925686
Suffolk
(County)
QJbr (Cmmiimuupalth nf HHaHBarljuHrttB
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
(City or Town)
No HI
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
3
f (If death occurred in a hospital or institution,
St. ) give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
V. '’■pn f’t i Y: ' ■ . f (Was deceased a
2 FULL NAME - .. " (U. S. War Veteran.
(If deceased is a married, widowed or divorced woman, give also maiden name.) I if so specify WAR)
(a) Residence. No K.Y.V.
(Usual place of abode)
St.
Length of stay: In place of death
10.
years months days. In place of residence years months days.
50.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DRATF?* Vtu dry — Cs- l ‘r (i ‘Y
(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 CT .m.
INTERVAL
BETWEEN
ONSET AND
DEATH
( (iJV /
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
IV e & vi Wt o L IV
Co-r-owav y' cl { a K i 6 Vy
A b h . - <->. fi /y due.
!bfl: h. N.d-ilr. (
n T U CY t-k*.
Due To < \ / ) / /
(c) * L. 1 i- *x..L. o.£..Ct
%
W S vy 'Tty S <£* p O -e- t*- f v
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? jl
What test confirmed diagnosis? ^ I V7 1 C, A— I ’ ^ O t
What test confirmed diagnosis? ™...h!hL!.™_™...! 1./...!...™ ! ' .(..
5 Was disease or injury in any way related to occupation of deceased? /I ®
If so, specify ,J...
(Signed)
(Address)
Au„kh. i.u.h. /1...L..
(PRINT OR TY^E SIGNATURES — -
J&jOULSk £ZGJL£ tw. ..7.?/** .
... M. D.
.xi.kMr.
re;
.00. ^ .
6 ■L.av-.’n
Place of Burial or Cremation (City or Town)
DATE OF BURIAL & 19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED ■ j
or DIVORCED
10a If married, widowed, or divorced j j
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
7 NAME OF
FUNERAL DIRECTOR -10. ■ u -- a..- Wj.
ma i%4
age.64 1 .. .. 24
..Years .^....Months t>ays
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Est .imtor
(Kind of work done during most of working life)
14 Industry
or Business:
Steel Co
15 Social Security No.
lfi BIRTHPLACE (City) £
(State or country) . C 0 t LS
17 NAME OF „ , ...
father Croiton McLeoc
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Katherine Smith
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
nova Scotia
21t . . Doric McLeod
informant «•••»
(Address)
nr op
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with ane BKFOREqthe burial or transit permit was issued:
ADDRESS
A.jji.nii.'.u;
Received and filed
(Registrar)
: filed with ane BJiFOREothe burial or transit
/ (Signature of Agent of Board of Health c
' (Signal
(Official Designati
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
:d for burial permit
Board of Health
• its Agent.
STRUCTIONS
FOR
U CERTIFICATE
T OR TYPE
1 OR CAUSES
DEATH
not enter
re than one
se for each
), (b) and (c)
does not mean
ode of dying,
heart failure,
etc. It means
•.ase, or compli-
which caused
lions, if any,
■ gave rise to
cause (a),
g the under-
cause last.
iditions contrib- .
) death but not
to the terminal
condition given
42-932382
i
®lj? (EnmmmuuntUlj of fSasBarljusrttH
3 Suffolk
|Q (County)
Winthrop
I(j (City or Town)
z No 6.5 Cottage Park Road
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
1 4....
Registered No.
((U death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME • .Q®£.Y.®.iY. L« / (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) J U. S. War Veteran, »T
V if so specify WAR) 1)1.0
(a) Residence. No 6.5 Cottage Park. Road 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 4.0. years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January. 8 19.6.4
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
Nov , 23 , 19-6.3...., to Jan , 8.., 19 .6.4
I last saitllGilal ive on ..tTiS.O.lJl.clXr.y. 0..# , 19..^.^death is said to
have occurred on the date stated above, at • m.
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
DivoRciW i do we d
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Generalized carcinomatosis
(b)6..1 Carcinoma head of pancxfif
Due To
(c)
Left inguinal hernia
OTHER
significant Ge ne rail zed
conditions arteriosclerosis
INTERVAL
BETWEEN
ONSET AND
DEATH
2 mos
retd
8m os
lOyrs
5 yrs
Was autopsy performed? .h.O
What test confirmed diagnosis Clinical & labor at o
5 Was disease or injury in any way related to occupation of deceased
If so, specif
(Signature) f. .. \ . . .'. *r.V.W. ....... Pff. , M. D.
M., Tr.aunste.in,, Jr/,VM, D,
(Address)
oiniMisseisg.. jan-8^64
6 Winthrop Winthrop
Place of Burial or Cremation (City or Town)
...January !JU 19.64.
DATE OF BURIAL
7 funeral director Arthur Maley
address Winthrop Mass
Received and filed
101964
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
_ (Give maiden name of wife in full)
. Joseph F . Garvey
(Husband’s name in full)
(or) WIFE of..
12
AGES
..Years Months..
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : HO.US.eW.if. ft
(Kind of work done during most working life)
14 Industry
or Business: C/WH HOflie
15 Social Security No..
16 BIRTHPLACE (City) BOS tOH
(State or country) " Mfl 53 R
-y
17 NAME OF
FATHER
Edward Cummings
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF mother Catherine
Brown
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Ireland
21 Informant
(Address)
Huth. Garvey
65 Cottage Park Road
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fileiFT^ith me BEEORJjL the bpfial or transit permitjwas issued:
jrfSigdature of Agent of Board of Health or other)
..uf...Z?.X. ^.y.../.$....&..^...
/(Date of Issue gif Permit)
Designation)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RECEIVED
W)
JAN 1 0 ISS4* *n'
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
d for burial permit
^oard of Health
r its Agent.
iTRUCTIONS
FOR
U CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
■e than one
se for each
, (b) and (c)
does not mean
>de of dying,
heart lailure,
L etc. It means
a se, or compli-
which caused
lions, if any,
gave rise to
i cause (a),
j the under-
cause last.
ditions contrib- .
death but not ^
'0 the terminal
condition given
2-932382
i
©Ijf (Unmmmtuindtlj nf fHaaaariiuapttfl
h Suffolk
[W
(County)
\o Winthrop, Mass
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
5
Registered No.
I W
[u
p Winthrop Community Hospital ((If death occurred in a hospital or institution
No .C! V St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME..
Albert E. Keleher
(If deceased is a married, widowed or divorced woman, give also maiden name.)
.. J (Was deceased
) U. S. War Vete
V i f so specify W
Veteran,
ARL.
no
3 Woods ide Park
(a) Residence. No St..
(Usual place of abode)
Length of stay : In place of death years months.:*: days. In place of residence.^1 Q.years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
■v<y.a a V<VW4
(Month) * '(Day) (Yea
(Year)
F Y , That I attended deceased from
& 19.V$
E R E II Y C £ _R T I F
Va* A 19..
I last saw h*. fMhve on .. \A .^1™ , lf^wjideatJ^ is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
Due To
(c)
SIGNIFICANT A S.W ■ ^
CONDITIONS <X O V OL. *
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? ■: ».».
What test confirmed diagnosis?
5 Was disease or injujy in any way related to occupation of deceased?
If so, specify
w*
(Signature)
(Address)
... M. D.
M.H
6 Holy hood Cemetery Brookline. Mans
Place of Burial or Cremation (City or Town)
(City or Town)
date of burial January. 1.3 1 S.h...
7 funeral director Arthur. J... Q.'.Mal.e.y
address Win throp^.. Mass
Received and filed
IS3
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED ,, . ,
widowed Married
DIVORCED
UNKNOWN
11 If married, widows qrHiv oreed .
husband of y.Pf a ...wei.se
(Give maiden name of wife in full)
(or) WIFE of I
(Husband’s name in full)
AGE £
Tl Years Months..
Days
If under 24 hours
Hours Minutes
Occupation Retired Salesman
( Kind of work done during most working life)
14 ordBus7ness:. Paper Products
15 Social Security No.. _O24-0'3-0^?9
16 BIRTHPLACE (City) BOStOn
(Stale or country) MaSS
17 NAME OF
FATHER
James B. Keleher
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Julia Donahue
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Ireland
21 Informant Cora Keleher
(Address) ^ Woods ide Park, Winthrop
(Official Designat
(DatS/Gf Issue of
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
£ 0 c ! V ED
JAN 10 1964 PH
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 ol 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.
I R-301A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
lot enter
than one
for each
(b) and (c)
oes not mean
e of dying,
heart failure,
etc. It means
;e, or compti-
vhich caused
■ms, if any,
;ave rise to
cause (a),
the under-
cause last.
itions contrib- ^
[death but not ^
the terminal
mdition given
| Chapter 137,
954, requires
f>s to print or
! cause or
f death on
| tificates, and
48, Acts of
Quires Physi-
print or type
ler signature.
-59-925686
< *W*!**k**j* Suffolk /J. I a
n (County) “
QJhr (£mmmimiiralth of fUaflHarljuflrttH
u.
o
u Winthrop
u (City or Town)
x no. Mount j£ei.t Home
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No
6
2 FULL NAME..
((If death occurred in a hospital or institution,
St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
Michael White iuV SS WaraVeteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) I if so specify WAR) No
(a) Residence. No. 93 Bellingham Avenue
(Usual place of abode)
St.
Length of stay: In place of death years.
months
36
Revere
(If nonresident, give city or town and State)
days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 death31!. Janua ry 13, Z.9.fs.?t.
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, That I attended deceased from
Xr.<?....b. 19.('3.^jo.. -ZZCc.ld....! 19.G.^
I last saw h^ucvalive on .*.J..Q..VL..*..J..3.....,( , 19.^:.'/'., death is said to
have occurred on the date stated above, at .?4SA..&. ..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
(•j Ck. u C ^ ^ o 5 ••
(b)e £4 Y
>-£ yo Q 6o kko
Due Td
(C)
, A o £ ^ ./ i uc? v t aiac/ /yvcjfS '
OTHER
SIGNIFICANT
CONDITIONS
jfSj.h fij <£L
Was autopsy performed? J \t. u ...1
What test confirmed diagnosis?
Jt.
INTERVAL
BETWEEN
ONSET AND
DEATH
/ vv.
■f
$ hlCSr
5 Was disease or injury in any way related to occupation of deceased
If so, specify y
(Signed
^ M. D
liMiiizin qm.rai.a.'
EE)
Da t e. . /./' Jj./
. . i (PRINT OR TYPE SIGNATURE)
(Address)lyi1/..f./)/^L.(./..Ji\..Q..(?....../$/..$.SS.
..19 C
6 ..HOLY ..CROSS 1LD.I
Place of Burial or Cremation (City or Town)
DATE OF BURIAL Jan*17,19$4 19..
7 NAME OF
FUNERAL DIRECTOR
Arthur S JPOrc el la
ADDRES5876 Winthrop Ave,, R^ver e
Received and filed
JAN 151964
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED ,.r. j
or DIVORCElWldOWed
10a If married, widowei nr divorced
husband of Nellie .uo.yle ..
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE... .84 ,.Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Retired-
(Kind of work done during most of working life)
or Business: Iron Worker..
15 Social Security No [removed] A
16 BIRTHPLACE (City)
(State or country)
Newfoundland
17 NAME OF
LA '_HKk Michael White_
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
' New found! ari d
19 MAIDEN NAME
of mother Susan
not known
20 BIRTHPLACE of
MOTHER (City) ....
(State or country)
Newfoundland
21
Informant MrW^e.rald.White
lA’M'-r-"1 _ 2B-7-^evere 3t», Winthrop ===
I HEREB\ CERTIFY that a satisfactory standard certificate of death
filed with m* BEFORE the burial or transit permit was issued:
2k.
1/
'/ (Signature^ of Agent of Boafti of Health or other)
te of issue// Permit)
(Official Designate
X
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TDVv
• •* •
\ QS,
s
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice: . — _ . t u
(1) Attending physicians will certify to such deaths only as thoe* hi p4rs£ilG Stj fill
to whom they have given bedside care during a last illness froul kskeaJs Wi‘v,VJ
related to any form of injury. - —
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by-
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
R-301A
! AUCTIONS
I FOR
k CERTIFICATE
living
IF DEATH
pes not mean
o) dying,
heart failure,
etc. It means
e, or compli-
•hie h caused
Imj, if any,
I ave rise to
Kcause (a),
the under-
ause last.
m lions contrib- .
fleath but not
the terminal
ndition given
Chapter 137,
154. requires
s to print or
cause or
death on
ificates, and
|48, Acts of
Uires Physi-
iirint or type
ller signature.
|-S9-92 5686
3 death)F January
14,
1964
(Month)
(Day)
(Year)
&
(Tbr (Cnmmmiumilth nf fHaaflarhuBrltH
s ^““4 in
(County)
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
t ;:w j fJf
[U (City or Town)
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
No.
LI Buckthorn^ Terras St. |(If dea,h ““ -e • ,n a- ho-sp,tal or i?s,itut-ion-'
2 FULL NAME
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
Fl 4h |uWSSuTrVeedeaan.
(If deceased is a married, widowed or divorced woman, give also maiden name.) ^ if so specify WAR)
St.
(a, Residence. No. ...^IJucIct Terrace
(Usual place of abode)
Length of stay: In place of death . . .. .. years months days In place of residence....: years....4:.1;. months "^r. ; days,
(If nonresident, give city or town and State)
‘ ; months 7^7 /..X
MEDICAL CERTIFICATE OF DEATH
4 1 HEREBY CERTIFY, That I attended deceased from
Dec 9 , i63. .... to January 14, 19 64
I last saw tiSJalive on .... January. 1.3*, i<6.4 ...., death is said to
have occurred on the date stated above, at .4 ®.f. m.
8 SEX
9 COLOR
Female
Viihite
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cerebral hemorrhage
Due r° Art e r i os. c le r ot ic and
(b)
hypertensive heart disease
Due ^Generalized arteriosclerosis
(C)
OTHER
significant Diabetes mellitus ,
conditions severe
INTERVAL
BETWEEN
ONSET AND
DEATH
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED .
or DIVORCED:, (.me d
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Frederic^
(Husband’s name in full)
11 IF STILLBORN, enter that fact here
4 hr& Ll lr
^ AGE Years Months.t.Z Days
n usual House- if e
Occupation:
(Kind of work done during most of working life)
VP! 14 Industry
■5.,.yrj
If under 24 hours
Hours Minutes
or Business :
Own Home
15 Social Security No.
— YTj 1 16 BIRTHPLACE (City) .
5-
(State or country) : - - • L »
Was autopsy performed? HO™.,., ji
What test confirmed diagnosis? Clinical & laboratory
5 Was disease or injury in any way related to occupation of deceased? bQ
If so, specify
(Signed) .. % , rn ' , m d
M Traunst e in , Jr* , M . vd *
(Address)
73 3l'rtt'&tVfftlS^i;ran.i4. 64
Wintnrop.Mass . 0*2152 . izz
6 .Ifopdiam._Cr„ema.tfirj.. LY.s.r.e..t.t.j,....i:&ias*...
Place of Burial or Cremation (City or Town)
DATE OF BURIAL 16 19.6./*..
7 FUNERAL DIRECTOR
ADDRESS i..A : <?
lf1M4
Received and filed
.19
(Registrar)
17 NAME OF , , „ , , .
father Axfred Simmons
18 BIRTHPLACE OF
FATHER (City)
(State or country) Eiiclaild
19 MAIDEN NAME
OF MOTHER
Sadie Merrit
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Horwell
»
21
Informant ,..i..+..§..Ci.SJ!i.pa.v.. ,.A....3.t&iii£Qtf.th..
(Address) 41 :Yru. ,. rr.'", —
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
was hied with me BttUKt me Dunai or tran
...CS,J...
' (Signature of Agent of Board ftf Healtl ,
* i\-x
(Official Design^jan)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
......
RULES OF PRACTICE
JAN 15 196**
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceas«l 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
IUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
for each
(b) and (c)
es not mean
of dying,
heart failure,
■tc. It means
' or compli- p
hich caused
ns, if any,
ave rise to
ause (a),
the under -
ause last.
lions contrib- ^
'eath but not
the terminal
ndition given
Chapter 137,
154, requires
s to print or
cause or
death on
ificates, and
*8, Acts of
tires Physi-
rint or type
:r signature.
•59-925686
i
ulbf (Enmmmtuiraltli nf MaaBarljUHrtti*
JOSEPH D WARD
l< \ . , r~ T-.n t / 1 , 1, ■ ^ i SECRETARY OF THE COMMONWEALTH
\u) J> ...O.. 7 ±O.Ld Wlh If DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(County)
S Li!.! XiTjK 1 ? j> WL y.
U (City or Town)
i N„ B.A.}f 1/lEW HURS-iHfr .fimE
me @L. i V£:. /s..: i's S'.O. l \
(If deceased is a married, widowed or divorced woman, giv
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
8
((If death occurred in a hospital or institution,
St | give its NAME instead of street and number)
2 FULL NAME
(a) Residence. No.
(Usual place of abode)
e?L0 Aj C L-' .o ”/
e also maiden name.)
St.
PHYSICIAN — IMPORTANT
f (Was deceased a
..( U. S. War V’eteran,
(.if so specify WAR)
Length of stay: In place of death W ...i
/o
months
n
(II nonresident, give city or town and State!
days. In place of residence. .(2^.. .years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
.dA..id.A., dM-.lt.
(Month) ((Day) / (Year)
4 1 HEREBY CERTIFY, That I attended deceased from
.Ma&.±. L.£r , to j.&y i9.<^
I last saw h£LS?alive on , death is said to
8 SEX
9 COLOR
J < kVVtL (-C
bv U 1
have occurred on the date
tin?.y , 19^i. If..., death is said
t stated above, at m. INTERVf
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Bj'L.AT..^RAL
/‘HFuuiefi \A
Due To
(b)
Due To
(c)
SIGNIFICANT DjJ-
CONDITIONS AJnETt.f'oSCLfAXrr /cyi
INTERVAL
BETWEEN
ONSET AND
DEATH
yes
Was autopsy performed? „....ihr.
What test confirmed diagnosis? .. C..L\.A\^AL....±.L.A.i.oM^
5 Was disease or injury in any way related to occupation of deceased? .tS&.
If so, spec!
IV..—! v.
(Signed) .0^-...: i /jDL.4? , M. D.
^.».XE./t.!r>...rti.r£(..d...r.ai..ti..i^..;..A
(PRINT OR TYPE SIGNATURE)
(Address)? . /j£^.....19...^?.i^
6 6w' Li..L.’.si l 0 ..UL..LL
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
7 NAME OF
FUNERAL
, taiiy or
-AgrYV <5
Af€frye%
_Z_
'Cs Li
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGH§..7!.Y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
/Vf; /K'^wv. — Ubo Se Oe&fl1*-1!
(Kind of work done during most of working lift)
14 Industry A t /
or Business : ...T.Xi R..<?.kk3^L
15 Social Security No }X £
16 BIRTHPLACE (City) 0 tf.CJ.S..T*.!C....
(State or country)
ADDRESS
, D IR E CTO ^ ^ // * S A ■
S..3.3 fe(S[.L.j!,..0‘- jri u % y ,
17 NAME OF
FATHER
J.C Ilcl bod t)r>w a // Sou. /'ill.
18 BIRTHPLACE OF
FATHER (City)
T$q
(State or country)
‘ At*
fat
19 MAIDEN NAME
OF MOTHER
£
t c/f~
21
Informant
(Address) JL 1
/ /
...
„ ^ /LLCU k/ /its r£ —
) jpl '/ fact ,At T^- ( As <- J
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
Received and filed
JAN 1-71964
(Registrar)
I IIERF.B\ CERTIFY that a satisfactory standard certificate of death
was J3ed with me BEFORE th^ burial or transit permit was issued:
(A... . ■ ■ ..r,.+
/ (Signature of Agent of Board of Health i>r (other)
fafa./.. -OO /- /?- (/■*/_
(Official Designation) l> (s (Date of Issue of Permit)
i
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT.
SERVICE NUMBER..
A..rf.43.!
;
■Xviri^ ”
......
'Ml
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice: lApJ i ‘J IQrA Pff
(1) Attending physicians will certify to such deaW^onlsLay thwse of persons
to whom they have given bedside care during a la'sf 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.
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-305 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.)
25M-4-59-925100
R-305
©Ife ©ommonfoealtlj of jdUflaBsadjusetts
JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
Melrose
(City or town making return)
X
I
Middlesex
1“ (County)
(U.
)° Melrose
/Id
lO (City or Town)
\«J „ TT R-i H crpunnH T.flnp f (If death occurred in a hospital or institution,
No a. St. ( give its NAME instead of street and number)
Registered No.
9
« full name... John Gustayson. f|fr #2v&L., ,.
(If deceased is a married, widowed or divorced woman, give also maiden name.) (if so specify WAR) £y.Q..,
(a) Residence. No l....terill...Terrac.e St Winthrop, Mass.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months....! days. In place of residence... 35. ..years months days.
MEDICAL CERTIFICATE OF DEATH
death"1™ January 17. 196k
(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.)
Heart Disease - presumably
Corona
(sudden death)
S Accident, suicide, or homicide (specify) HP.
Date and hour of injury 19..
If accidental, was injury causally related to the death?
Where did
Injury occur ?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in
public place ?
Manner of
(How did injury occur?)
(Specify type of place)
Injury
Nature of
Injury
While at work? PO Was autopsy performed ? ....HP..
6 Was disease or injury in any way related to occupation of deceased?. JPO
If so, specify
(Signed) Thoma.s...Z.« Devlin m. p.
(Address) Stoneham, Mass. Date...i?H. •17i9
7 Wint.br.Qp
Place of Burial, or Cremation. (City or Town)
date of burial January.....?.!^ 19. 6k
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Male
10 COLOR
White
11 SINGLE (write the word)
MARRIED an/4
widowed Married
or DIVORCED
11a If married, widowed, or divorced
husband of Anna .. .Larsen
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 IF STILLBORN, enter that fact here.
13
AGE...&5... Years 7. Months il...Days
If under 24 hours
Hours Minutes
14 orcmLtion- Painter
(Kind of work done during most of working life)
IS Industry
or Business:
Contractor
16 Social Security No
.Q25-.QX-d.995
17 RTRTHPT ACF. rCitv^
.Unable to obtain
(State or country)
Sweden
18 NAME OF
FATHER
Gustav Johanson
H
Z
19 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Unable to obtain
Sweden
w
X
<
20 MAIDEN NAME
OF MOTHER
Gerda (unable to obtain)
21 BIRTHPLACE OF
MOTHER (City) .
Unable . to.... obtain
(State or country)
Sweden
22
Informant Anna Q.us..ta.vs.o.n.
(Address) 1 Bur rill Terrace. Winthrop, Mass_.
* funeral director ...HQward.S. Reynolds
address Winthrop. Mass.
A TRUE COPY
ATTEST:
Received and filed ... JAN.344864
(Registrar of City or Town where deceased resided)
DATE FILED
$ •s&lj&v\£cujJ0.
(Registrar of City or Town where death occurred)
January 21* 196U w„
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
t 0
JAN 311964
uhjp viinOTmnnuTpaiuj m MnaaBanjuama
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
1 10
Registered No.
2 S.....u£tQ...U<.
]Q (County)
)° \a// N TH/LA0
(City or Town)
Ax ft 1/ r~ / st i .x- " S) t\i fvS) /- . / f (If death occurred in a hospital or institution,
No/xV/t i C?/..M.[SA...hr. St. { give its NAME instead of street and number)
2 FULL NAME.. ...A.M..US..XA L, Skj.J±t±h.K
(If deceased is a married, widowed or divorced woman, give also maiden name.)
»
(a) Residence. v/.fl/ '? SHtRA&ft S - St
(Usual place of abode) f (If nonresident, give city or town and State)
Length of stay: In place of death/l&.years months days. In place of residencexZ.^years months days.
PHYSICIAN — IMPORTANT
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
i~7
(Day) /
(Year)
4.1 HEREBY CERTIFY., That I attended deceased from
, 19 to Q..J 19
I last saw hiiilhlive on ..JA.&A.:. Lkr 19^?.# death is said to
have occurred on the date stated above, at ... ’J.ilZAr... m
8 SEX
9 COLOR
10 SINGLE
(write the word)
FCha a l lL
w h jT F
MARRIED
WIDOWED
DIVORCED
UNKNOWN
W ! <0 O' kV'
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ...Cs.A.£.a
Due To /''V
(c) Ur..fc.
rPTF/liiei -
E it-CT'S
OTHER . , . . T-
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
3 cL
X/%S
my/RS
Was autopsy performed? Ilfi?
What test confirmed diagnosis? .CJL.Uj t.A.L..±AA&i
5 Was disease or injury in any way related to occupation of deceased?
If so, specif
(Signature)
■fu
, m. d.
12.HXZ MU±^IJS^JL
6
Place of Burial or Cremation
jLxJL/k -JLZL7Z
(City or Town)
DATE OF BURIAL
....19.^.#
7 NAME OF
FUNERAL DIRECTO
ADDRESS
Received and filed
tm. T 7 1964 ,
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE
(Husband’s name in full)
12 A1'* *-*-* /i~j 71*
age*?:/.. Years. / Months.. .5 Days
If under 24 hours
Hours Minutes
U Occupation:
(Kind of work done during most working life)
14 Industry , * , , '
or Business: /\S.
15 Social Security No.
16 BIRTHPLACE (City) fcf.A Jr.U'.
(State or country) A! . J> +
17 NAME OF
FATHER /JAvTA/,/)
i-y/?//* a /g
18 BIRTHPLACE OF
FATHER (City)
(State or country)
A/ 6 Y A- S 04 £_j_±
19 MAIDEN NAME
OF MOTHER £ LL £ N /T /JT /? /V /£
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
t jcaf/A
21 Informant JN A.A.jL.
(Address)
w.AL,piTt at/aaa /
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
sA • (F ^ .....
, v (Signature.) of Agent of Board of Health or other)
(Official Designation/ (Date oj^fssue of Pertfiu)
l/.f ~ ^
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
c T f
•A
jSNITliiSS'Wi
RULES OF FRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
X
12 (County)
fW ^ ...
$1 7? (HmnmmuitFaltfj nf HHaBaari|Ufiftt0
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
II
Registered No.
(County)
STANDARD
(City or Town) CERTIFICATE OF DEATH
/ j~ Y jO /£. // / / // /T \ T~ I (M death occurred in a hospital or institution,
No./(t?...y( . L. . k.. TT. St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME.. ((Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) \ U. S. War Veteran, , y ,,/y
(.if so specify WAR)
(a) Residence. N0../2O. £Jj£M£ S,
(Usual place of abode) (City or town and State)
Length of stay: In place of death. ./^/.years months days. In place of residencel£j?.years month
dav
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T„ , 0 ,
death Januar.y....l9, 1.964
(Month) (Day) (Year)
4 I HERE I! Y 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.....Z. ;..,m. ,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .Cor.onary....Dcclusioa
(b)e...To. 3 imahl3r.....due.....ibo
Due To causes.
(C) *7! ■ 4- ■ T! — ■ .pr ... .1 < '?^*Tf7TPT*| Pp-.-v L.Vvpj.
OTHER
SIG N I F ICA NT „. 1 '.
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 ../l ...
(Signature)
M. D.
F-. •' i.......'.....,.'.....,
(Print or Type Name)
(Address) ' ’...' r-.yy: .k. ....’:,:.a^.r.. Date ... v, l..y. 19
:. MMyjaa. ■„
Place of/Burial or Cremation (City or Town)
DATE OF BURIAL 2..X. 19,<£
7 FUNERAL DIRECTOR £l.A.
a ddr ess ..£j.AL£X./£A£.. Al.A..£..:„
Received and filed
JAN 2 1 1964
19..
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
ks/-/jr^
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED .,-/■)
UNKNOWN / / A JP/? A' JJ
11 it married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
AG
E L£.
Years Months Days
If under 24 hours
Hours Minutes
13 8EU- D.S...Sj.Ay£1 f
(Kind of work done during most of working life)
'* AuuYAMJtL
IS Social Security No . .A. 2-£
16 BIRTHPLACE (City) 9. . . .
(Stale or country) /~Y /f, J J
17 NAME OF „
FATHER J ///*( /A/-
Dt-fA/V,
18 BIRTHPLACE OF , . .
FATHER (City) /.AAJ.A.AA.
(State or country)
19 MAIDEN NAME
OF MOTHER Q # rnJ.~ /?//?£ J- / /
20 BIRTHPLACE OF
MOTHER (City)..
(State or country)
/
21 Informant ./.£££:.
, Add, ess, J£±£AM/M.E. £.....££ry££
I HEREBY CERTIFY that a satisfactory standard certificate of death
wa,s filed with nje BEFORE the burial or transit permit was issued:
jLddL
(Official Designatiop)
Signature of Agent of Board of Health or other)
(Datejol Issue of Permit)
VJi ^
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE....^.* Ll/.t..
DATE OF DISCHARGE...i^..Z.....^...../.^.^
RANK, RATING £ff£SKll£. §£ASJJJ.L
ORGANIZATION AND OUTFIT
SERVICE NUMBER Z..£:AZ...:£Z.
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.
— a
.......
V. rv<
......
JAN 2 11964 pm
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-301
for burial permit
ard of Health
ts Agent.
IUCTI0NS
FOR
CERTIFICATE
OR TYPE
>R CAUSES
)EATH
ot enter
than one
for each
(b) and (c)
>es not mean
oj dying,
heart failure,
i tc. It means
or ccmpli- p
kick caused
i ns , if any,
save rise to
cause (a),
Ike under-
r.ause last.
lions contrib- ^
i leatk but not
tke terminal
ndition given
2-93E553
\l
4^ (ml
v
O (County) \
(City or Town)
\<
uty? (Cmnmmuuraltlj of fSaasarljuarttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
12
2 FULL NAME
^M.y. z^zzz mem. ' st.
ANN& M9H/?
((If death occurred in a hospital or institution,
l give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(W as deceased
) U. S. War Vete
\if so specify W
3 Z
Length of stay: In place of death years months. .-rf... days. In place of residence.!?' years months days.
Veteran, ,
(a) Residence. No St..^...^
(Usual place of abode) _ n (City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
...X. A-TIrv.
(Month)
O
1.1..A /
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
’y.2t...Vx.r. /.£ , \9...6 h:Q. 19.. la.../...
I last saw h.«*r.alive on j^.<5L...kV* , 19^.^., death is said to
have occurred on the date stated above, at /A.U.CM. .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
f_*.i.fc..v:..e.
Due To
(b)
..f/jZ.M.I k.k\..f:.£...C....i../:...2...^..
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Os. A/aasUi&..
INTERVAL
BETWEEN
ONSET AND
DEATH
y<z
3 d
Was autopsy performed? .......
What test confirmed diagnosis? ...
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature) /...f. / Z..4.:...V_. Z...A— .( Z.nsw..., M. D.
Z„U.A.jr...[..T...i : :
(Print or Type Name)
(Address) .IZ. Date .yyXj....L.. 19.
6/
cr/P*sj
Place Burial or Cremation (City or Town)
S/.d./Y.. A.?.. i
DATE OF BURIAL
7 FUNERAL DIR ECTO R
ADDBESS
Received and filed V..V? . "
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
y^/z/r^
10 SINGLE
MARRIED
WIDOWED
(write the word)
DIVORCED A /A/£/-£
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
V 2"
AGE(/iZ Years. Months
Days
If under 24 hours
Hours Minutes
AAtiC.AL'M.. FJ? AC rtf/?
(Kind of work done during most of working life)
14 Industry
13 Usual
Occupation
Business AQ.ltCP.Az
15 Social Security No. // & P pi
16 BIRTHPLACE (City), .JT^CP.^P.P.A
(State or country!
17 NAME OF
FATHER
18 BIRTHPLACE OF
zow
CF. OF Z ~
ZfZ///P.
D1K iniLALt ur 1 m J A At i /
FATHER (City) (fS./T AA..A.. Aj A,
(State or country) '
19 MAIDEN NAME
OF MOTHER /f/V P jA
Zf
20 BIRTHPLACE OF r _ t
MOTHER (City) Y. Z. '/..C/Z /Y...f..
(State or country) /t r & ,
: ,
jj/tss*.
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
■ / j Z—.i . s Y
(Signature of Agent of Board of other)
-J&L
S IIICU
...Ca
(Official Designation)
(Date of Issue of Permit)
i
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 observalAa if^Jhf? K "i/i { \
following rules of practice: Is o IvJ •
(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.
v" TOly-
\
-/yv U 6 '• ;
/^re-
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-301
(for burial permit
Jard of Health
its Agent.
AUCTIONS
f0«
CERTIFICATE
OR TYPE
|R CAUSES
*EATH
at enter
than one
for each
b) and (c)
es not mean
oj dying,
heart failure.
•Ac. It means
e, or ccmpli -
thick caused
■ns, if any,
ave rise to
ause (a),
ithe under-
ause last.
\tions contrib- ^
feath but not
the terminal
ndition given
o.
2-93E553
K
$1jf (Eommmtuibaltlj of HRapaarljuafttH
am
ID (County)
)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this returh
STANDARD
CERTIFICATE OF DEATH stered No jLllJS..
((If death occurred in a hospital or institution.
2 FULL NAME.
(City or Town)
no.Jl^ A..t£... St. I give its NAME instead of street and number)
/ \ ' PHYSICIAN — IMPORTANT
r£A..a... Lai aajx. .1 &AA....IJX..
(If deceased is a marked, widowed or divorcetKwoman, give also maiden name.)
/ (W
1U
V if s
as deceased a
S. War Veteran, A / si
so specify WAR)
(a) Residence, AtA. St.
33. Sj/,
(Usual place of abode)
(City or town and State)
Length of stay: In place of death.yT^years months days. In place of residence.y^^years months. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
ETA ^
(Month)
33
(Day)
w
(Year)
4 I HEREBY CERTIFY ^ That I attended deceased, from
7. 19 2y~. t, -J 4. A' 30 -.6 A
I last saw ht^/alive on ... UQM. .3.0 ..., 19..^^death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(aC ' fe; ti.VU D.X.X U « y
^.er.(g.i>W. ^..e.\u qx.y.Iix |
Due To,
(b)
l^.x...^.T.L..p...x.c./e..r.. ss/Jl/ls.k.isM.1..
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
JJa.
WjS,.
INTERVAL
BETWEEN
ONSET AND
DEATH
4 aft
'!fl
3L1Y5 e
Was autopsy performed? j..
What test confirmed diagnosis \ j..,4 L?.L. At /..
5 Was disease or injury in any way related to occupation of deceased
If so, specify ^ v A
jLo
(Signature)
jSMj&j. LLQ...€..i&/.A/v..
/ !*( ay
6 .ttALV. Q.A1.S.S 34.AAA.AR...
Place of/Burial or Cremation (City or Town)
DATE OF BURIAL
AAR JL
19.
FUNERAL DIRECTOR /A/1A.R...R.Al... t£.. R/R.R..X-
CZ.A../3.AA3...
ADDRESS
Received and filed
JAN311964
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
As/fAA Atf/r A
10 SINGLE (write the word)
MARRIED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ..A.A.R.A../3.J).
(Husband’s name in full)
12
AGE 7 / Years Months
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation.
KialX ARJA.R/f:. ( R.AZ/A.A.r).
(Kind of work done during mok. of working life) '
14 Industry
IS Social Security No. 3/ A/ A3.
16 BIRTHPLACE (City).
(State or country)
,/^f * ff
17 NAME OF r
FATHER QZ/AJp/rS /-// AS/ *
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
aiauA/j O y/p
IF
20 BIRTHPLACE OF ~
MOTHER (City) 0...4./3..3..A.3r...
(State or country)
21 Informant
(Address)
LAam./.S.A. /3AS...£.rr.L
3.A3.M.3..^
(Official Design;
h me BEFORE the b
Bo
(Date of issue/dfF
AQJ.
re of Agent of Board of Health or other)
1 j / /J £ c£
(Date of Issue /SI Permit)
I
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
i 0
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.
JAN 3 1 1960
I
/
AH
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.
Xfe
OUT OT ©1?* (Enmmmiuipaltlj of fHasaarfiuartta
" j\N KEVIN H. WHITE
Suffolk: r T*'-1 Secretary of the Commonwealth ’
" Ijsl 1^,, P DIVISION OF VITAL STATISTICS (City or Towr. making this return)
2 FULL NAME
STANDARD
CERTIFICATE OF DEATH
14
turn)
^COdOd
(County)
Boston
(Cityortown) CERTIFICATE OF DEATH
ja Veterans Admini s tr ation Ho spi t al «.h
PHYSICIAN — IMPORTANT
William J. Shannon
(If deceased is a married, widowed or divorced woman, give also maiden name.)
) (Was deceased a
) U. S. War Veteran,
\if so specify WAR).
WWII
(A) Residence. No 12.6. BaPML - *5 E‘. 203 J^.3S »
(Usual place of abode)
(City or town and State)
Length of stay: In place of death years months 13 days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ..
J anuary
(Month)
2 1964
(Day) VA (Year)
4 I HEREBY CERTIFY, That 1 /at tended deceased from
..D©q.# .2.0. .9.63 to Jso,* 2. 19 64
xxKtzxzxxajfizaxxxxxxxxxxxxzxxxx .. death is said to
have occurred on the date stated above, at t 4-0A. ..in. INTERVAL
BETWEEN
ONSET AND
DEATH
days
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
Male
White
WIDOWED
DIVORCED
UNKNOWN
Single
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Pneumonia
(a)
Due To
(b)
Due To
(c)
other Ri<?ht neant ■Tpilui'p
SIGNIFICANT "...“x X.f
coNDrnoNsArteriosclerotic heart di:
15 Social Security No..
ITo
2 davs
16 BIRTHPLACE (City).
£asg_yrs. (State or country )
Was autopsy performed?
Wha, test confirmed d.agnosis? . Clinic al & Lab... Findings
5 Was disease or^njury in any
If so, specif.
related to occupation of deceased? ...
(Signature) ..krAiC
Eug.ene... A
(Print orType Name)
(Address) V AH. f. . BQ . S. t Q.h. .M.&.S.SL* Date. Jj3h#.2 19.. ..64
Winthrop Com., Winthrop, Maas.
Place of Burial or Cremation (City or Town)
January 7 ,, 64
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Kirty Funeral Home
ADDRESS i
Received and filed _
/jftft W
V," (Registrar)
PERSONAL AND STATISTICAL PARTICULARS
II If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
AGF.
61y,
Months
Days
If under 24 hours
Hours Minutes
13 Occupation Truck Driver
(Kind of work done during most of working life)
14 Industry
or Business..
02 5-09 -7 609
Boston
rlas3 ,
17 NAME OF
father Edward Shannon
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston
Mass.
19 MAIDEN NAME
OF MOTHER
Mnry G1 11
20 BIRTHPLACE OF
MOTHER (City) S. BOStOU.
(State or country)
-Mas &-
21 Informant Y.». A* Ho spi. t al . Reco rd s , 150 5.
(Address) Islington Ave., Boston, Mas.3*™
m *7 Ti _ 4.-™, C!1 TT> -d_~ a. __ „ J HEREBY CERTIFY that a satisfactory standard certificate of death
SrJL I Benm ngton wt., n. DOS won, * &3i%s file^LwiDptne BEFORE the burial or transit permit was issued:
roTgnature^f Agent of Board of Health or other)
'pA%..
(Official Designation) ' (Date of 'Istae of Permit)
A TRUE COPY ATTEST:
45g:,.:
3 \
FEB 28156*1 M
FORM R-301
d for burial permit
loard of Health
its Agent.
TRUCTIOKS
FOR
l CERTIFICATE
„ -■CgagerT.iaa’ei i mo" re cll—Pi-^i'd-
2 FULL NAME.. v.
i&G-
r or type!
OR CAUSES
DEATH
not enter
e than one
e for each
(b) and (c)
ioet not mean
de ol dyinf,
heart I auure,
etc. It meant
lit. or eomfli- .w
which canted
iont, ij any,
lave rite la
came (a),
the under-
came loti.
i iiliont contrib ■
| death but not '
I o the terminal
I'andilien liven
a
I * s 1964
1
U >2-934553
QYc (*) Residence. No - — - - - Si
' (Usual place of abode)
Length of stay: In place of death years months il.days. In place of residence 4 5 ears months d
K
QL .
l< Suffolk
]— (County)
©Ijp (EnmmxJnuipaltli nf ISJaBBarljuafttB
Boston
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
15
(City or Town making this return)
no i;V)
Registered No.
xt„. j n 4. „ „ tt ji.i „ ((If death occurred in a hospital or institution.
No and tenter Hospital St. | give Its NAME instead of street and number)
— PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
26 Sturgis Street, ‘"inthrop. Mass.
(Was
) U. S.
(.if so
as deceased a
War Veteran. T.TA
specify WAR) ArN/.tt
(City or town and State)
ays.
MEDICAL CERTIFICATE OF DEATH
3 i‘»fIthof January 5 196U
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
January . 1... 19..6I1 to January 5U 19. 6 14.
death is said to
I last saw iQ.palive on January $
have occurred on the date stated above, at Hi2$a
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
widowed
female
white
DIVORCED
UNKNOWN
1’ If married, widowed, or divorced
HUSBAND of
Y: IMM
AUSE
SICNTFICANT >
CONDITIONS'/^ ^ ' - '' ' '~
Was autopsy performed?
What test confirmed diagnosis?
ovi.
INTERVAL
BETWEEN
ONSET AND
OEATM
*4^
LjA 4. .
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
Alan ?isch '
M. D.
(Address)
(PHfitor Type Name)
Date.’
6 $1 nt.hr op .Cemetery, ...Wint hr op,
Place of Burial or Cremation (City or Town)
Januar
DATE OF BURIAL
8.1964
7 NAME OF
FUNERAL DIRECTO
address 1.7,4 ffint/rop St„f Y/in t Lr c„P
r T ’’
Received and filed _ we-A- f»V ~~yl9.Jj.’.i..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(Give maiden name of wife in full)
(00 wife of y/illi.ajn....Ha Pettinge.il.
(Husband’s name in full)
AGE
•; Q8 Years 5
Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation housework
(Kind of work done during most of working life)
14 Industry
or Business..
own home
5 Social Security No. [removed]
16 BIRTHPLACE (City).
(State or country)
..Palmyra"
Paine
17 NAME OF
FATHER
hi Hard Filmore Field
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Palmyra
19 MAIDEN NAME
of mother ^ouisa El i z abe thx Bxaekg
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
7
Oron.o Brackett
L'aine
21 Informant R.Q.b.e.rt....M...E*P.ield
(Address) Herring Run,Y/e.st Harwich.
Mafc$
(Official Designation)
a satisfactory standard certificate of death
the burial or transit permit was issued:
of Beard of Health or other)
ihA^
(Date of issue of Permit)
TV l
A TRIIF. rnPY ATTFJtT?
A ^<UE COPY ATTEST:
City Registrar
. 1 '>’■ '•> ■■
> .-• -v \
M«s ' ■ *
\sV.
FEB 28186A M
wljr (Crtmtnamuraltfj at ISaeaarhuBPlta
OffOLK
(County)
(City or Town)
No.
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
16
(City or Town making this return)
no ISO
Registered No.
2 FULL NAME.
fiern X^fcACL
IQcwto ook-ke
!(If death occurred in a hospital or institution,
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
nmm - I (Was deceased
(II deceased is a mflrried, widowed or divorced woman, give also maiden name.) J U. S. War Vete
V i f so specify W
^iftcoYr XlL- s. U ,
Length of stay: In place cf death years months..
eran,
ART.
(a) Residence. No I'M...
(Usual place of abode)
s. v dmwit-. In place of residencojy . years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 ^athof. to v
(Month) (Day)’
(Year)
4 j HEREBY CERTIFY , JThat 1 attended deceased from
MN..! (q I9....U.H to ,v3aB-N)..-. k.„ 19 ...fa'l...
I last saw h.\l>\alive on ... ifft 19 (jfj death is said to
have occurred on the date stated above, at .^..i.^$ Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ....Lo&*£. y\o»oi/\ .....
Due To
(b)
Due To
(c)
MFICANT C0NG^TW£ V)^T LV^-r
OTHER
SIGN
CONDITIONS
INTERVAL
BETWEEN
ONSET ANO
DEATH
3 tA'ys
Was autopsy performed? .... No
W'hat test confirmed diagnosis?
S Was disease or injury in any way related to occupation of deceased Ho
If so, specify ..
(Signature) |r~V.V~rN)s* XT ./V-.. M. D.
.ScaoAVeti
««*», %v> WSSSSK&L
WtMTMKeh 2. wmmrzop
’lace of Burial or Cremation (City or Town)
yJMMffARyL ? .9
Place
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
/hextfux s L&MaJey...
UijMltilG'M . Mass
/A'/?
c/
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
/Vale
9 color
W *\TB
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED
UN KNOWN i
11 If married. widoVr/[ or di
HUSBAND of
TtgLMvA 1Empp$,
(Give maiden name of wife in full)
MaASIEG.
(or) WIFE of .
AGE^7.Ve
(Husband's name in full)
Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:..
jfejfm O £L£C TRK/AM
(Kind of work done during most of i working life)
14 Industry
or Business
tf- S . AZa^C //><//* J?D
IS Social Security No..
16 BIRTHPLACE (City).
(State or country)
'CUBLSeA
MAS s
17 NAME OF / /
FATHER K/OP/\t VV
18 BIRTHPLACE OF
FATHER (City)
(State or country)
St v^/Y/V
/V- B-
19 MAIDEN NAME
OF MOTHE
■K H &nki e tta Johns ro m
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
MAS £
21 Informant
(Addre
fiSLZMA E. QtfXKE
ss, J3</ W/umtnp
I HEREBY CERTIFY that a satisfactory standard certificate of death
v^:-Lyas filed- with mf^EFORE the fjurial or transit permit was issued:
(Official Designation)
D
.//6.K..
of Issue of Permit)
▲ TBIIF mPY ATTFQT
FEB 281564 M
)RM R-301
for burial permit
ard of Health
t. Agent.
UCTIONJ
roii
CERTIFICATE
I not meam
ol dyint.
earl latlure.
Ic. II meant
or compli- .
Air A canted
.Jl eonlrib ■
•alb but mol
MAe terminal
ion (ivn
3
6°.
: pl
ft 1964
4-934553
_ 1
1
SOTTI
Suffolk
(County)
Boston
(City or Town)
utyr (Emnmmuuraltl] of fHaflearijuarttfl
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
17
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
JlDSlll
Registered
jjj Veterans Administration Hospital gj ((If. death occurred in a hospital or institution.
2 FULL NAME.
Terrance S.
Placido
•a — «-»». t give its NAME instead of street and number)
( 'ij vri'. Physician — important
(If deceased is a married, widowed or divorced woman, give also maiden name.)
rWus drrY h^nil-a
U. S. War Veteran,
if so specify WAR)..
WWI
<„ Residence. «■ s, tf^throp, Has 3.
(Usual place ol abode) •
Length of stay: In place ol death years.T*. months.^ days. In place ol residence O ...years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 death* January
— 5
1964
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
(Month)
(Day) ,VA
(Year)
Male
White
WIDOWEDm„— — 4
im oKCKiMarri ed
UNKNOWN
1 hat .4/ at tended
Ian. o'
deceased^fjjmi
XttXXXXXl^Wxxxxxxxxxxxxxxx
have occurred on the date stated above, at *.m.
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Metastatic carcinoma to both
lungs with-lef-t pleural
Due To
(b)
effusion ^primary .undetermin >d
Due to Hypercalcemia secondary to
(c)
OTHER
SIGNIFICANT
CONDITIONS
neoplasm
INTERVAL
BETWEEN
ONSET AND
DEATH
mos .
vks .
Was autopsy performed
TNo
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
, M. D.
Jo el E. CahnilTa ~ >
.. 64
6 Winthrop Cem., Winthrop, Mass.
Place of Durial or Cremation
(City or Town)
DATE OF BURIAL 9...j 19...6A
7 fune”ral director
w f ■> / j *
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
HUSBAND ol .
(or) WIFE of..
liary Morrissey
(Give maiden name of wife in lull)
(Husband's name in lull)
12
AGE'
67
.Years
Months
Days
II undrr 24 hours
Hours Minutes
13 Usual
Occupation .
Truck Driver, retired
(Kind ol work done during most of working life)
14 Industry
or Business
15 Social Security No . Q 1 1 mJL.Q ”... 7.Q..I2..
— Boston
16 BIRTHPLACE (City)
(State or country)
Mass.
? . Clini c al & Lab. '|*indingf • father Patrick Placido
17 NAME OF
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
Mary Desamone
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Italy
2. Informant V. A. Hospital Records, 1% S.
Huntington Ave., Boston, Mass.
(Address)
1 .r* tr, , , 0, TT. , , [I I HEREBY CERTIFY that a satisfactory standard certificate of death
ADDRESS 14.1....r*i..h.VAi‘0P bt » , Wint&TQPn M.&9 > • »»» TNed wift^e BEFORE the burial or tran.it permit W«I issued:
St
(Signairit of Agent of Board of Healtlyor other)
1 Ycc'So-. U&Cte -
(Official Designation) (Date ol Issue of Permit)
LJ Pit »
Lit* A
fi £ C E V --
FEB 281964 M
FORM R-301
d for burial permit
ioard of Health
its Agent.
’.TMCTIONJ
FOR
10. CERTIFICATE
IT OR TYPE
OR CAUSES
DEATH
not enter
c than one
te for each
, (b) and (c)
I3oei not mean
I tde o) dyinp,
I heart failure,
• , tic. Il meant
I ate, or compli- .
a which canted
If torn, il any,
| pave rite to
i caute (a),
ft? the under-
R caute loti.
tdition t comlrib-
■ > death but not *
x o the terminal
N condition eivem
lu|\C •
V
P8 1964
p2-933U0b
,
OWN
GJl|? (Cmmnmiuiraltl] nf fHaBHarfyuarttfl
p
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIF CATE OF DEATH
. 18
(City or Town making this return)
004 -I.'?
Registered No.
LS<l£EaJl<
(Qojmty)
t CUs-foef
(City or Town) k<Crt I IT L.M I C. wr ULH I rt
so..Cj. </mh u S ..JXURS L W.& O PJM e,. s,.|(K?acm
I PHYSICIAN — IMPORTANT
/(Was deceased a <v /
(II deceased is a married, widowed or divorced woman, give also maiden name.) A U. S. War Veteran, l\/
, V i f so specify W A It i
red in a hospital or institution,
E instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME
(a) Residence. No ^.6
(Usual place of abode)
..St
J^ikik
Ron
‘ (City
(City or town and State)
I.ength of stay: In place of death years months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
rvm !'/
(Month) (Day) (Year)
4 I HERE II Y CERTIFY, That I attended deceased from
19 A’/r. to rrr.. nAtA
1 last saw hi^alive on .. J-/m. ... death is said to
have occurred on the date stated above, at m.
8 SEX
9 COLOR
a 1 e
M/Vi /c
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
De
(a) s
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed ? ±9
What test confirmed diagnosis?
S Was disease or injury in any way related to occupation ol deceased? ft
If so, specify
(Signature) }.^J. . . .££ £. fit*. . . .It. S, .Tfm.x ,
.'.7?^.^. ^
ToaIS&m
x M. D.
(Addr
HjL/ Ci
Place oy Burial or <
tJSS.
Cremation
DATE OF BUR I
^ X/L.H.X. I
(City or Town)
F V NL K A L DI R
AD
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
II If married, widowed, or divorced
HUSBAND of
10 SINGLE (write the word)
MARRIED
WIDOWED | • .
DIVORCEDi J/ . J
u n k n ow n VY iclo jj eci
(or) WIFE
— r- (Give maiden naa»e.of wife in full)
of...\J..flm<r..s X>. ±..c..d../s..&Ii.
(Husband’s name in full)
AGF.ff&>Y
ears Months Days
If under 24 hours
Hours Minutes
Occupation: t~j f) ^
(Kind of work done during most ofiworking life)
14 Industry
or Business:
0 oO /-/ o yr\ C
15 Social Security No..
16 BIRTHPLACE (City).
(Stale or country)
Al eu/i ro A a ct !a filet...
17 NAME C
FATHER
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
Ep^E/Vk' l?>/0esv At/td
M Q4,/ -/tieSAci trtrtc/
19 MAIDEN .\WrM4v~. x ^
of mother ti/Qtc/Gef K oc<ye.
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
AlcuJ fiJJn'r//# rlcf
21 Informan
(Addre
Mft-AJSlZ. K..y £sa 2 /<-<
I HEREBY CERTIFY that a satisfactory standard certificate of death
Med with me BEFORE the burial or transit permit was issued:
JAN 20 E$4
(Official Designation)
. dnJUM&iU
‘A (Signature of Agent of Board of “Heal til or
A TRUE COPY ATTj
A iRUE COPY ATTEST:
City Registrar
'
Ov-tt;
•
. • A A ..
. :•••• \
- j •
■ . - .
■•A ;> ,/x .
%80P>’
FEB 281964
R-302
C *o^
* V «
|sJ
u “d
°-S -
W 4- U
Sxco
•c.u .
115
OJ
„ c a
C— rt
-X
•o §<->
flj >
!>
•o >,-d
4> ^ 4>
Pa
y « u
y£ o
73 •*-* O
r°%
4» U. »0
(A 47
«J — V
O «£
*
li2 Norfolk.
IQ (County)
)° Wellesley
f[j (City or Town)
'3 X,. .Wellesley Manor
(Ulj? GLmmnmtiupaltij ni MaBHanjUHFtla
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
19
Wellesley
(City or Town making this return)
COPY OF
CERTIFICATE OF DEATH
Registered No.
8
No..
f (If death occurred in a hospital or institution,
■St. ( give its NAME instead of street and number)
2 full name Mary McJMiald
(If deceased is a married, widowed or divorced woman, give also maiden name.)
{ (Was dt
< u. s. w
I if so spe
deceased a
7ar Veteran,
specify WAR)..
<„ Residence, n. l6 Johnson Avenue, s, wmthrop
(Usual place of abode)
Length of stay: In place of death years months days. In place of residence years months days.
(City or town and State)
S 2f
o >
~ CM
leg. 5
o'?
>.«•£
•Bel
u O ^
v
3 E"
| S "
O a}
J= ~ u
u
1-
v £
_ s
>-•£ a
° « „
qj
C
x « «
- E i
-•£tj
U «
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January 1.4, 1964
(Month) (Day) (Year)
4 I HEREBY CE.RTIFY, That I attended deceased
January.., 19 . 63 - to January 14, 19 1
1 last saw h.©.Xfive on January 14 ... 19... 6^ath is said to
have occurred on the date stated above, at -3 Re. m.
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
Female
White
WIDOWED
DIVORCED
UNKNOWN
Widowed
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ..... Rheumatic. Hsartj Dil36.a.8.fi
Due To
(b)
Due To
(O
si™! fica nt General Arterloscler
CONDITIONS 03 IS
INTERVAL
BETWEEN
ONSET AND
48
TH
Was autopsy performed? No
What test confirmed diagnosis? .... X-Rays- Lab ora t ory
5 Was disease or injury in any way related to occupation of deceased? NO H
If so, specify
(Signature)
..Mo.rr.l3 Ringer. m. d.
Morris Ringer M.D.
(Address)
851 Beacon St. ,
Newton Me
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced
HUSBAND of ..
(Give maiden name of wife in full)
(or) wife of Matfcew L» IJcDonald
(Husband s name in full)
3 AGe82 . Years 11 Months 1 4
Days
If under 24 hours
Hours Minutes
IS Social Security No.. None
10 yjjfSlfi BIRTHPLACE (City). . SO*. BOStOH...
(State or country) Mp S SI -
6 Wlnthrop Gem.*., Wlnthrop.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ^.7.4^ 1
6J
7 NAME OF
FUNERAL DIRECTOR
Richard C. Kirby In< .
address 917 Bemln&bon St . ,, .E,Bost( n TRUE COPY
Received and filed EA.ki.jL (%H£ 19 ATTEST:
(Registrar of City or Town where deceased resided)
13 Usual
Occupation:.
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
At Home
1/14. -19 & *
17 NAME OF
FATHER
Jo3eph Shaughnessy
18 BIRTHPLACE OF
FATHER (City)
(State or country) Mass.
19 MAIDEN NAME
of mother Katherine Sullivan
20 BIRTHPLACE OF
MOTHER (City).
(State or country) Mass.
Boston,
21 informant Mrs* Martha J . Gilligan - Dau.
t \ddress) 1^ Edgewater Drive, Wellesley
DATE FILED
C.
(Registrar of City or Town where death occurred)
'' January 1 6 , ,,.64.
if M v
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT.
SERVICE NUMBER.
* •
:.t /
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance 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.
- -
v
FtB W
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
>ird of Health
ts Agent.
RUCTIONS
for
CERTIFICATE
OR TYPE
3R CAUSES
DEATH
tot enter
than one
for each
(b) and (c)
Mi not mean
e
t) dying, Cj
heart failure,
etc. It means £-t
it, or compli- ^
' S
Em, H any,
ave rise to
'cause (a),
Ike under-
cause last.
J3
ilions contrib-
talk but not
Ike terminal PI
lion tiven
o
pi,
■i0'
£
JO
w
GO
a
o
i-J
O
2
:
M-93USS3
uJfj? Qlnmmonuiraltli ai fSafisar^uarltfl
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
go...
(City or Town making this return)
<>0580
Registered No
Suffolk
(County)
Boston WJ/ STANDARD
-~gsr~ TWO CERTIFICATE OF DEATH
Pp+ p y» Rpri F Ry.4 ohain HoqoT "f* fOf death occurred in a hospital or institution,
No St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
) (Was deceased a
1 U. S. War Veteran, t/y //, >7"
\.if so specify WAR! fr /elA S/
27^Court R<i* $0C
>f aboae)
Length of stay: In place of death years.. months.. ..^-dayy^ In place of residenejj^. years months days.
L.
full name Robert Reese
(If deceased is a married, widow
dowed or divorced woman, give also maiden name.)
(a) Residence. No..
(Usual place of
..Winthrop, Mass •
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF . ^
death Janua rv lo.
(Month) *' (Day) T
1)964
(Year)
TWer E R E U Y CERTIFY, That WSttended deceased from
• Jan. 15 .. 19....64 . to Jan. 16 19 64
Wa-< saw hJLKhve on Jan. 16 , 19...64ealh is said to
have occurred on the date stated above, at4 J 45A . m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cirrhosis with gastro-
Due -intestinal hemorrhage
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
8 SEX
tf/iur
9 COLOR
fP/Y/Tf
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED /*fp/PA)/f/)
UNKNOWN '' ' ^
11 If married, widowed, or divorced
HUSBAND of
/r'AC./.Q tf...
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE?X /.Years
Months
Days
Was autopsy performed?
What test confirmed diagnosis?
Yes
Autopsy
S Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
(Address)
PBBH
(Print or Type Name)
L»tcJ 169.1.^, ^ °
6 Jfc/MFtfSes/*
Place of Burial or Cremation (City or Town)
DATE OF BURIAL H.'f.AY...... A.A.
7 FUNERAL DI RECTOR
A DDR ESS
re.. .
(RegisTTSf
PERSONAL AND STATISTICAL PARTICULARS
If under 24 hours
Hours Minutes
13 Usual P/P A P
Occupation /.L.G'./...;
(Kind of work done during most of working life)
14r&ss. /*4/e/fs...
15 Social Security No. (r'A .**' . S~ Y
16 IHRTHI'LACE (City) K>('^....T.PA/.. .
(.State or country)
17 NAME OF __
FATHER \/S//y
-T /TP£S £
18 BIRTH TLACK OF / , . ^
FATHER (City) \....Y./Y... t^.. ^.P.^/.A'.. ../...
(State or country)
19 MAIDEN NAME
OF MOTHER yPfP/py /T &C//VA/
20 BIRTHPLACE OF ' .
MOTHER (City) C.pJx../.\...
(State or country)
21 Informant
SMOiL
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was iisued:
ficial Designation)
J
f Board of Health or otheO
I
(Date of Itsuf of Permit)
tl
A TRUE COPY ATTEST:
FEB 281964 AM
m R-301
r burial permit
d of Health
Agent.
im"s
RTIFICATE
l TYPE
CAUSES
i|ath
enter
>n one
|r each
and (e)
not mean
ol dyinf,
t rl I allure.
. It means
or cempli - .
:k caused
I •'/ toy.
|t rise to
vie (a),
Mt under-
t so lost.
|a> contrib-
i Ik but not *
e terminal
n lion riven
■
1
h?
In
1
¥
B13U553
o, q (Cmnmxitmiraili) of
'S‘/s KEVIN H. WHITE FWJL
(City or Town rrfatliii^^^/t^tiuki)
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
/^i£U±L
(City or Town)
STANDARD
CERTIFICATE OF DEATH
Registered No.
l~ J/ O tT /- ■ 0 Ji A '7 TfliF/t ///■< P • ((H death occurred in a hospital or institution.
No t....L.±..!L....Z..l UJLLLA.Al Li..'./.. St. | give us NAME instead ol street and number)
2 FULL NAME.
<\7'
// jO
S *6
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman
^3
i, gi^^al
so maiden name.)
(a) Residence. No £...... Q. St
(Usual place of abode) .
..months. It days. In place ol residence (s....y
J (Was deceased a , /
) U. S. War Veteran. 1A. .
(.if so specify WAR) //U.
/i/ {as*- J . 7 -
/ "'"(City’
or town and State)
Length of stay: In place of death years..
ears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF ,
DEATH /..
(Month)
.../Z.
(Day)
6 ^..
(Year)
That 1 attended deceased from
0> Cf
4 I HEREBY CERTIFY
3. Vt.J&.M.., to J I...J....1... 19.
I last saw ht^/alive on , 19..^.f^death is said to
'J O '
have occurred on the date stated above, at .... J.V'. —Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Hodgkin’s Disease
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
tfj£±£.
A'
c w ‘or.yt-iii My -
Was autopsy performed?
What test confirmed diagnosis?
3s:
INTERVAL
BETWEEN
ONSET AND
DEATH
yr s ,
5 Was disease or injury in any way related to occupation of deceased?
If so, specify —
(Signature) Itj'..- 'i.i/!Z....^..3/AA.... M. D.
..... L.LLL.£:..A... ‘ZA
,r„„, no
Place of Burial or Crematio
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
^7c~. S£m.Idikx^:
Received and filed f. . iMv/l. 19. ..S...
/Or
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
AJAi
10 SINGLE (write the word)
MARRIED
WIDOW I
DIVORCET
UNKNOWN
li'j.fsW
II If married, widowed, or divorced
HUSBAND of
(or) WIFE of....AJ 4l4JLa
ife in full)
tears Months Days
13 Usual
Occupation.
14 Industry
or Business.
(Kind cf work done dfr most of working life)
'Op'
IS Social Security No
./Gi:7— /f Wau/si/
16 BIRTHPLACE (City).
(Stale or country)
17 NAME OF
FATHER
dlAlM-A(C
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN
OF
IDEN NAME AD . .
MOTHER xArtAjjZ.
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
21 Informant
(Address) .3 /. *
ddf,. }/duL-U..
EREBY CERTVFy that a satisfactory standard certificate of death
s filed with me JliFQRE the byTial or (P5^s>t, permit waa issued:
ed with me 7TEFQI
(Signature of Agent of doanThK Health or other) /~\
•.... Ua^./ir A£c/
(Official Designation)
(Da
Iaaue of Permit)
A TRUE COPY ATTEST:
wh*
\
—
FEB 2 BISS'! fitl
>RM R-301
for burial permit
>ard of Health
ta Agent.
IUCTIOKS
I C E RT I F I CATC
IDR TYPE
Ir CAUSES
eXth
lit enter
< han one
l^gr each
, b) and (c)
|:i not mean
ol dyint,
•tori Jjit Jure,
ft. tl means
i, or comfit- .
kick caused
lm. if any,
i tie file to
tute (a).
| he under -
i use last.
JURISDICTION WAIVED
IX AT Tl
Suffolk
(County)
QJfyr (Eommunuiraltlf of UlaBHartiuflrllH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
p DIVISION OF VITAL STATISTICS (City or Town making thia return)'
o * ,rr STANDARD
Boston / i
(City or Town) CERTIFICATE OF DEATH
no New England Deaconess Hospital s,. iWt*? N^MklnMe^^'^'er^d^rmCi
PHYSICIAN — IMPORTANT
2 full name !^.s. Norah ...Bateman (nee. Ogden) ./(W», deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) j U. S. War Veteran,
lif so snecifv WAR1 AtM
{ \i
Registered No
(a) Residence. No MJLOCUsfc Ss.^^P.P.t **SS
(Usual place of abode) jg minut<.s
Length of stay: In place of death years months days. In place of residence. J»...yearsQ months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 death* F January 20 1964
(Month) ' (Day) (Year)
4 I H E R E II Y CERTIFY That 1 attended deceased from
January 19 „64 to January 20 ( i<,64
I last saw ex.alive on .. .January 20 , |9 64 death I-. said to
have occurred on the date stated above, at 12:08 A
*m.
8 SEX
Female
9 COLOR
Yfhite
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCE!) . . , _
UNKNOWNS ldov/ed
11 If married
widowed, or divorced
HUSBAND of
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
NfMQCPrRDirvL IrslCfYftCT
(a) CAOIMmGs JWjTE
(b)e..I°. AftTHRa o Sct^RoSi s
Due To
<c)
other Ii> t fvfecns Heu.trus
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Vlxwis
5 '-{n
Was autopsy performed? .... ftSL
What test confirmed diagnosis? *<■
S Was disease or injury in any way related to occupation of deceased?
If so, specify lit).
(Signature) W M. D.
fV.*...Sx7tMmN:
(Print or Type Name)
(Address) l\).e\5L3X.t.H-* Dat<*i.QUA.s£0.....19...fe.V<.
6 Forest Dale Cemetery .....Malden....Ma s s
Place of Burial or Cremation (City or Town)
DATE OF BURIAL January 23..
7 FUNERAL DIRECTOR .Q.Ol.ln..-H .* DOXUliS.
address .....1.44. Salem St Malden Mass.
ffied
JAW
A TRUE COPY ATTEST:
...19.._.
gistrar)
PERSONAL AND STATISTICAL PARTICULARS
(Give maiden name of wife in full)
(or) wife of Charles 3.* Bateman
(Husband’s name in full)
AGF. 63 Ye
Months
10
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation.
House wife
(Kind of work done during most of working life)
or Business At Home
15 Social Security No Unobtainable.
16 BIRTHPLACE (City)..
(State or country)
LancJaisnie
England
17 NAME OF
father Arthur Ogden
18 BIRTHPLACE OF
FATHER (City)
(Slate or country)
Unobta inable
England
19 MAIDEN NAME
OF mother Unobtainable
20 BIRTHPLACE OF
mother (City). Unobtainable
(State or coun.ry)UnQbta j_nablQ
2i informant ..Erank....B* Bateman
(Address) .12 Tufts street Malden..
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with^PF BEFORE the burial or transit permit waa iiaucd:
lure of Agent of Board of Health or, other)
(Official Designation) (Date oFIssue&f Permit)
FEB 2 81964 at
>RM R-301
(or burial permit
ard of Health
ta Agent.
UCTIONJ
MR
icmmcm
I OR TYPE
|r causes
bEATH
>« enter
fthen one
I (or each
i, b) and (c)
el not metn
el dying,
tetri failure,
■ic. It meant
> or compti - .
kith reared
In, ij tty,
I me rile to
lease (e),
mka under-
\tuit last.
m iott conlrib-
lull but mot '
I lka larmimal
i id titan given
,c
opp}
^ y
v°
I '2 8 1964
M-93U55)
X
OUT -OF
l W f
]3 (County)
fe G.o.s^r.cf4
/(j .(City pr Town)
<
\i No
Uttj* QJnmttuimupaltlj nf fflaBBadjUBFttfl
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
23
(City or Town making this return)
00801
Registered No.
2 FULL NAME
Ada Altshuler
I (If death occurred in a hospital or institution,
..St. I give its NAME instead ol street and number)
PHYSICIAN — IMPORTANT
(K deceased is a married, widowed or divorced woman, give also maiden name.)
A
(a) Residence. No
(Usual place ol abode)
65 Beejch Road Wlnthrop,Mflss*
j (Was
) U. S.
*if so
as deceased a
War Veteran,
specify WAR)..
M..o...
..St..
(City or town and State)
Length of stay: In place of death years months days. In place of residencel^. years months days.
MEDICAL CERTIFICATE OF DEATH
1 death0!!. January 23,1964
(Month)
„(Uav)„
8 SEX
Patient
19.
, death is said to
have occurred on the date stated above, at ... ll.J4.Qam
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cardiac. arrest E
in- H#s'i / „
AGF.LCi '^'t ears Months Days
^r... Myocardial Inf.ar.c fcion
Due
(c)
Horonary Atherosclerosis
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Hrs.
ion.
Was autopsy performed? ..Yea
What test confirmed diagnosis? .. Autopsy
S Was disease or injury in any way related to occupation of deceased?
If so, specify ..
(Sign
W/QTM
(Address) .
,9P...
T
(Print or T
el
D.
6 /h.jO...<.JX..i..J”..»CtvL)C-
(City or Town)
Place ol Burial or Cremation
DATE OF BURIAL
7 NAME OF <1 „ \ s l
FUNERAL DIRECTOR H-M-tCj.i~.t~A Co
Avu u.a.&y. :2.h i9..t
VhWi-
A DDR ESSl L L i CJt.£..fi.CC.jrj )l.£.Ui\jrOL«.ir.s.g.
Received and filed i
JAM 2 8T5OT
A TRUE COPY ATTESTt
^^^R«i;i-r'.ri
PERSONAL AND STATISTICAL PARTICULARS
£ S IYi C\ Ct-
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED _ . _ _ _ .
DIVORCED CY\ AG-fL* CJL
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of .
' (Give maiden name of wife in full)
(or) WIFE of...r..n..Aaei CV..C...g £) L^...i..U.U...L..E.T5i
(Husband’s name in full)
If under 24 hours
Hours Minutes
13 Usual _ _ _
Occupation /..J .[■>.*•
1 (Kind of work done during most of working life)
14 Industry _ . . _
or Business.. ~f" A/ C./TJ -
IS Social Security No
16 BIRTHPLACE (City).
(Stale or country)
17 NAME OF
, W -AJ
L- L-
»THKK C..l - 1 1.0 V, a, a
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
C r i n u
20 BIRTHPLACE OF 0
MOTHER (City) Jn, W..C.S. ‘..*.L....
(State or country)
21 Informant .V Q i.!Y...V.\l.U.i-..G..y2.
(Address) (l. Ij t. £.w...k\.....*..V..C...a3.1
I HEREBY /CERTIFY that a satisfactory
w/ybJvl w/jyme BEFORE the burial
( ^
(Signature of Agent of Board ^Health or
tandard certificate of death
entit permit wae ieeued:
(Official Designation)
'l3cT»V
(A* V
(bate of Issue or Permit
mv
M "
.
FEB 2 8 1264 AH
)RM R-301
for burial permit
ird of Health
a Agent.
UCTIONJ
FOR
CERTIFICATE
|OR TYPE
■R CAUSES
•EATH
it enter
than one
L (or each
i b) and (c)
lei mol mean
I el dying,
\kearl failure,
I lie. II meant
t. or compli - .
rkick canted
ll nj. </ any,
lave rite to
Ira me (a),
like under-
lame (ail.
t ions conlrib-
• eatk but nol "
I Ike terminal
minion given
5
r /
1*
128 1364
■I Director!
uni only
AK Inlu
w -932382
Ci
SUFFOLK
(County)
uJtjp Qlomuuinuipalllj nf iHafiflarfjuaptta
<*\ KEVIN H. WHITE «
r— — \ Secretary op the Commonwealth
" B? 1 M. 3 DIVISION OF VITAL STATISTICS (City or Town making this return)
BOSTON 1 }? /J STANDARD
CERTIFICATE OF DEATH Registered No
No MASSACHUSETTS GENERAL HOSPITAL - - St. | give its NAME instead o( 'street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME I^trick.W.J
(II deceased is a married, widowed or divorced woman, give also maiden name >
...) (Was deceased a f 1 /"
) U. S. War Veteran, // /J
v i f so specify WAR!
(a) Residence. No.. ...11 Suratnit...Avenu.6 „.s. Wln.thrQp>...Haas.
(Usual place of abode) (If nonresident, give cil
Length of stay: In place of death years months..^... .days. In place of residence1^/ years months days.
city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF r«
h ...uanuary; ....
DEAT1
(Month)
23.
(Day)
12.6k..
(Year)
4 1 HEREBY CERT IF Y , That hmttended deceased Rom
January .lU. i9 6k. to January 23 it. ok
^ last saw h^UUlive on ... January 23 19.6k, death is said to
have occurred on the date stated above, at . k.:.3CLa.m.
DEATH WAS CAUSED BYi IMMEDIATE CAUSE
Acute tubular renal necrosis
(a)
('bjTStra-abdomina 1.. .he . rha "e
Jo' Abdominal aortic a..
..(I
sign ifica nt Burns ... .3 » bu 1 locks..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
8_days
9 days
UnljnQmL_
Was autopsy performed? nO
What test confirmed diagnosis? . clinical.
SLdays
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature) \nm<fl^r!^r.tCm^rr^!rd’iXmir^iimi* , M. D.
ChntUa L. Cley. M.D. /.
(Print or Type Nrtne)
(Address) A*»'t, Gf.n.'.L H*,W. DalrJUU *......23....19.Qa._
T7
urial or Cremation
Place
DATE OF BURIAL
7 NAME OF ^
FUNERAL DIRECTOR m2
(City or Town) ..
o ix.
XX'X'O
ADDRESS
Received and
is • • ,
zL — Jfiim i3b4 y ,
Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED CW J,
DIVORCED
UNKNOWN
1 1 If married, widoweRnr dworced
HUSBAND of
' (Gt/e maiden name of wife ip full]
full)
(or) WIFE of..
(Husband’s name in full)
AGE
fa. Ye
If under 24 hours
Hours Minnies
13 Usual
Occupation:.
.MonthsX. .$^?...Days
(Kind of work done during most working life)
14 Industry
or Business:
A/rr/7
IS Social Security No.. <>?- V#/ ‘7
16 BIRTHPLACE (Citvl
Ajxrt tJzn*.
(State or country)
! *
17 FATHER*
</)
H
2
18 BIRTHPLACE OF
FATHER (City)
(State or country)
o :
<
19 MAIDEN NAME /T) ft yj j s, ^
OF MOTHER /tcojL,
CL
20 BIRTHPLACE OF
MOTHER (City)
<3 S.l /
(State or country)
I HEREBY
waa file
TIFY that a satisfactory standard certificate, of death
e BEFORE the burial or transit permit waa iaaued:
Jc
Agent of Board of Health or other)
lpwti*
(Official Designation) (Datemf Issue of Permit)
A TRUE COPY ATTEST:
V E D
■ \.u:
FEB 28196^ M
RM R-304
In giving
AUSE OF
:al death
;o not enter
||>re than one
Ijse for each
•f (a), (b)
I and (c)
ml or maternal .
\ition causing \
t' death (do
■ use sue h i
rs as stillbirth /
urematurity.)
1/ and/or ma -/
n / conditions,
mr, which gave\
I to above '
u (a), stating ,
underlying /
l last. —
>i itions of fetus
fiother which
•l have contrib-
•/ to fetal
•S', but, in so
■is is known,
»i not related
h a use given
f).
4 SEX ,1
t
5 COLOR (if V
6 THIS BIRTH (Ch^k one)
7 IF ML
Male Female*?
r Undetermined
determined)
Single Twin *T Triplet
1st)
10M-6-62-933U-04
,> Suffolk
(County)
Win.thr.qp
(City or Town)
1°
5 no Win thro p community Hospital
2 NAME OF FETUS Cardoza , E.ab.y Gi r.l....#l.
(if given)
Slfje GJnntmoninealtJj of ^Massachusetts
KEVIN H. WHITE
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.
25
gt ) (If death occurred in a hospital or institution,
) give its NAME instead of street and number)
3 DATE OF O
C.
DELIVERY ‘
(Month )
(Day)
(Year)
7 IF MULJP4P’ '"-'BIRTH, BORN:
2nd 3rd
FATHER
full Arthur M. Cardoza
NAME
RESIDENCE, NO. 44^ llUTiner it* STREET
CITY OR TOWN E..EOStOIL STATE I:,
10 !acer or White
11 AGE AT TIME OF C
THIS DELIVERY ->
(Years)
12 PLACE OF
BIRTH
Poston,
(City or Town)
Mass.
(State or country)
OCCUPATION
Carpenter
MAIDEN NAME
PRESENT NAME
MOTHER
Catherine F* Aiken.
Catherine F. Cardoza
15
RESIDENCE, NO.
CITY OR TOWN
442 Sumner St.
East Poston, state
STREET
Mar ~
,ss
16 racer ORWhite
17 AGE AT TIME OF
THIS DELIVERY (Years)
is place oEagt Boston,
BIRTH
Mass.
(City or Town)
(State or country)
19
INFORMANT
Arthur M. Cardoza
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
(a) How many children are
now living?
r-3
(b) How many children were
born alive Lut are now
dead? QNone I
21 LENGTH OF
23
22 Weight Lb.
Oz.
DID FETUS DIE?
PREGNANCY
OF FETUS
Be for?)
During Labor
completed weeks
(or
Grams)
or Delivery Unknown
(c) How many previous fetal
deaths of ANY gestation
age? ^ /
24 AUTOPSY
Yes
No
: IM
pyo. w r / T-
25 FETAL DEATH WAS CAUSpD BY
(a)
Due To (b)
Due To (c)
OTHER SIGNIFICANT
CONDITIONS
MEDIATE CAUSE
26
Holy Cross
Place of Burial or Cremation
DATE OF BURIAL
Feb,
Malden, Mass.
(City or Town)
3 ,.64
27 fih$e^?al DiRECToF*'®<^-®^’i(-'^ sT* Ms.gra.th.
address325 Chelsea St, East Poston.
Received and filed
A TRUE COPY ATTEST:
(Registrar)
I HEREBY CERTIFY that this delivery occurred on the date stated
above at r and product of conception was not a live birth.
^nature of Attending ^Physician or Medical Examiner:
M.D.
(p R ^ (y * $J.h.
y (PWfNT CXOftYPE NAME)
Address^ ^ Date S
I HEREBY CERTIFY that a satisfactory certificate of fetal death
was filed with me BEFORE the burial or transit permit was issued:
/
iature of Agent of Board of Health or other)
(Official Desigruition ) (Date of Issue of Peri^m)
FETAL DEATH
</s
fx roiv
v Try)'"-.
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48.
ACTS OF 1960.
1 \
* vU
x:~'f
..s' f i
Section 2A. “Examination of records and returris^f'dU^gittmate births, or abnormal
sex births, or fetal deaths, . . . shall not be permitted
-<Zfm£P
Section 9 A. When a child is born dead, after a perTocTof gestation of not less than
twenty weeks, and in the fetus there is no attempt ^prearcir^imjiio action of heart and
no movement of voluntary muscle, the physician or officer attending at the birth of such
child shall forthwith furnish for registration, at the request of an undertaker or other
authorized person or of any member of the family of the deceased, a certificate of fetal
death on a form which shall be prepared by the secretary of state as required by section
sixteen. Town clerks shall record certificates of fetal death in the town register of deaths
in the same manner as a death certificate, but they shall not be required to record such
certificates in the town register of births.
Section 12. . . No birth record of a child born out of wedlock or of a child of
abnormal sex, and no record of fetal death shall so be transmitted to any other city or
town.”
Section 2k . 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.
Iw Suffolk
|Q (County)
®lj? (Unmmmiuifaltlj of fHaHaarijufirtta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
26
Registered No.
_ . n i (If death occurred in a hospital or institution,
No Vv i'RT/HFGp GGfflHiUni by H OS'P'i tVQl St- * glve its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Cardoza, La.br. Girl.. 2k J (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran,
Vif so specify WAR)..
(a) Residence No k.k L? L.. St-B- ... ( -E©Svt--On V'-'M ~
(Usual place of abode) (If nonresident, grve city
Length of stay: In place of death years months days. In place of residence years months days.
NO
own and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF n r -i rt / i
DEATH l.eb... 1., I.9.64
(Month) (Day) (Year)
4 I^HEREBY CERT IF That I attended deceased front
/ , ^.04 to..../Mr€^ J. ... 19.6..#.....
I last saw h.C.Vfaiive on J. , 19..(£../ death is said to
have occurred on the date stated above, at &*auL .m.
d
H WAS CAUSED BY: IMMEDIATE CAUSE
Vr> CLr&t I'f’ —
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
fn.n
Was autopsy performed? ... /I'M...
What test confirmed diagnosis? ....
5 Was disease or injury in any way related to occupation of deceased
If so, sp<
(Signatui^
... M. D.
../:. l/.lr t
(Address)
Holy Cross. Malden, Mas^
(City or Town)
Place of Burial or Cremation
DATE OF BURIAL
Feb. 3
,64
7 NAME OF
FUNERAL DIREC
Frederick J. Magrath
address?2?... Chelsea St, East Post oil.
Received and filed
..SK&Sr
..3...
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
Female
MARRIED
WIDOWED
White
DIVORCED
UNKNOWN
Single
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE Years Months Days
If under 24 hours
X Hour4X -Minutes
13 Usual
Occupation:.
(Kind of work done during most working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City)..
(State or country)
Winthror
Mass.
17 NAME OF
FATHER
Arthur M. Cardoza
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Post oh.
Mass.
19 MAIDEN NAME
of mother Catherine F. Aiken,
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
East Foston.
Mass.
,, . . Arthur M. Cardoza
21 Informant
(Address)
442 Sumner St. East Foston.
I HEREBY CERTIFY that a satisfactory standard certificate of death
w^s filed with me BEEpRE the burial or transit permit was issued:
^
/ I (Signature of Agent of Board of Heaith or other)
<MJc..d,...g..M...
i
(Official DesignatiorC)
(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
C
RULES OF PRACTICE f £fl 3 jgg/| ^
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
for burial permit
ird of Health
s Agent.
tUCTIONS
FOR
CERTIFICATE
4'? ft
OR TYPE
R CAUSES
5EATH
| ot enter
than one
for each
(b) and (c)
oes not mean
• of dying,
heart failure,
tc. It means
e, or compli-
'hick caused
s, if any,
ave rise to
cause (a).
I" the under-
ause last.
lions contrib-
ieath but not
I the terminal
II ndition given
-933404
Suffolk
(County)
)° .¥. in t hr op
I; j (City or Town)
\<
mqp ummmnnuipauij nx maaBanjuamB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return;
SSL
Registered No.
No..
B-.l.o Viking Gardens
f(If death occurred in a hospital or institution,
..St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME.. Fannie ( As t.r in ) Rosenthal
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Residence. No... E.-..LQ. Viking Gardens
(Usual place of abode)
(Was dece
) U. S. War
V i f so speci
deceased a
ar Veteran,
(y WAR)..
N<
(a)
St..
(City or town and State)
Length of stay: In place of death years 1. months days. In place of residence :..years nonths days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February 4, 1964
(Month) (Day)
(Year)
4 I HERE II Y CERTIFY
19 to
I last saw h alive on
That I attended deceased from
19
19 death is said to
8 SEX
F etna le
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
11 If married, widowed, or divorced
HUSBAND of
have occurred on the date stated above, at /f?«'30y4i m.
(a^?.9. 4.4, d <*.£. 4y<1 ( d««LS<?S
(b) fa ^ ^ ^-g;aL/y T fa M t V
€2
fife 0 V Q 5 €> d ho cf DQ&H \rilric{e>(
. ■jhl — <i~
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceasj
If so, specify
(Signature)
M. D.
(Address)"\A^.y.A-"T^T^ y^^ yl^3Ty(//19...4..^
6 Rabbi Isaac El chon on Cera .Ever e t
Place of llurial or Cremation (City or Town)
DATE OF BURIAL
...?..®.k« 5 ....
.19.
fsh
funeral director Mu.rr.a.y. Goldman
address i 7 4. ^ *rr y .? t • » ^ a 1 d e n,Ma s s *
Received and filed
FEB '61964
19..
( Registrar)
PERSONAL and statistical particulars
(Give maiden name of wife in full)
(or) wife of Hyman.. ..Rosenthal.
r..i
(Husband’s name in full)
12
If under 24 hours
AGE 7?Years
Months
Days
Hours Minutes
13 Usual
Occupation :
Housewife ■*
(Kind of work done during most of iworking life)
14 Industry
or Business:.
At home
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
«u s
s ia
17 NAME OF
FATHER
Max Astrin
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Unknown
Russia
19 MAIDEN NAME
0F M0THER Libbv (Unknown)
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Unknown
Ru s s ia
21 Informant Ed wa r d Rosenthal
49 Pearl Ave . ,4 intbrop
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
(Official Designat
-6'/, /^) ..<ft I .
(Signature of Agent of Board of Health or other)
A TRUE COPY ATTEST:
esignatiorv) !’ (Date of Issue of Permit)
w
4/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
t j
.F£.a.e.G.l366.iH
RULES OF FRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or cnanged, 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.
V VI
|>RM R-301
| or burial permit
I rd of Health
|a Agent.
AUCTIONS
OR
■ CERTIFICATE
OR TYPE
R CAUSES
I EATH
i>t enter
han one
for each
b) and (c)
is not mean
of dying,
i eart failure,
to. It means
|, or compli-
hich caused
Is, if any, *
tie rise to
Mouse (a),
&he under-
"tuse last.
ifli o
1 1 'a
ions contrib- ^
path but not
he terminal
'ition given
6.932382
SI
(Eommottuimtlj of fttaBsarljufiFttH
£ SUFFOLK
,<
w
]Q (County)
(U,
\o r
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
’Vinthrop
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
iu...vVlii.THiiQE
/( j (City or Town)
(5 w„ V/INTHROF COIWNITY HOSPITAL
Registered No v
28
t * . , .... ((If death occurred in a hospital or institution,
No t*. T. St. ( give its NAME instead of street and number)
PHYCIPTAM TMPDSTANT
, full name CATHERINE AMDER30H iKAYNEi) f(W„ .
(If deceased is a married, widowed or divorced woman, give also maiden name.) J U. S. War Veteran,
V i f so specify WAR)
NO.
<., n,. 94 JELLEVUE AVE_._, WINTHROP St ,
(Usual place of abode) (If nonresident, give city or town and State)
ys. In place of residence . .2. 5 ears months days.
Length of stay: In place of death years months.
MEDICAL CERTIFICATE OF DEATH
3 date of February 5 1964
DEATH
(Month)
(Day)
(Year)
4 I
BY CERTIFY . That I attendecL-deceased. fropi
vt.lt zJS... to /^..^TTidS... ....nJL.. 19.4.!^..
I last saw h. trAb ve on . f-L-fo ...S * J 9..S^b dea th is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Qerr u wc
(a)
Due To
(b)
° ....£.
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
// frlQ
Was autopsy performed? _
What test confirmed diagnosis? .. ft / css y rt-T
S Was disease or injury in any way related to occupation of deceaset^rfTlli'
If so, specify
(Signature)
vny
(Address)
4L d
yddMA/ Sr. dj)
- '“rint or Type ” ' ‘ ‘
/ A 'T~f+ri4'
6 Winthrop Cemetery
Place of Burial or Cremation
Iint.hr o.p,.Mas a
(City or Town)
DATE OF BURIAL .... February. 6 >1964
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
female I white
10 SINGLE (write the word)
MARRIED w-t Hr>WF»ri
WIDOWED WXUUWCU
DIVORCED
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of .. Charles Frederick .. .Mderson
(Husband’s name in full)
12
AGE 61 Years . 7 MonthslO Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:...
bookbinder
( Kind of work done during most working life)
14 Industry • « « « v • j
r ru imsspnmmeroial bookbmdery
15 Social Security No..
16 BIRTHPLACE (City).
(State or country)
0 11-20-04 41
Boston
Masaachns et ta.
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
William Henry Maynea
Dorchester
Massachusetts
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Mary Rose Regan
Londonderry
Ireland
21 Informant
(Address)
Adrian C. Anderson
94 Bel3 ftvue Ave.Wi nthron
■•it L HEREBY CERTIFY that a satisfactory standard certificate of death
MaShS Med with me BEFORE, the burial or transit permit was issued:
y? l A. . ' J i I i , t (fi^)
. (Signature of Agent of Board of Health or other) ,
<y/< c 1 1 ^ '
(Official Designation)
(Date of Issue of Permit)
dll
A TRUE COPY ATTEST:
K/r
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT.
SERVICE NUMBER.
u >
r \ .> s*.
RULES OF PRACTICE
< / -rs * (3 '
The fulfillment of the purpose of these laws calls for the observ^nce'tJf tW «*
following rules of practice: ’ / fjt) '■
(1) Attending physicians will certify to such deaths only as those of parities
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 raff those 6f lOR/i iiil
persons who, though disabled by recognized disease unrelated to ErtyUofm hf IJU > '
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.
>u-'i
CRM R-301
for burial permit
i>>ard of Health
t Agent.
AUCTIONS
FOR
CERTIFICATE
OR TYPE
)R CAUSES
>EATH
ot enter
than one
f for each
(b) and (c)
•es not mean
f of dying,
Heart failure.
Vile. It means
t, or compli- .
Vhich caused
s, if any,
ave rise to
ause (a),
he under -
ause last.
dons contrib- _
eath but not
the terminal
|l tdilion given
c .
-
-934.553
®lj? GlnmmmiuiraltJj of UtasHarljUHrttH
Suffolk
(County)
]“ Win thro p
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
2i)
Registered No.
No..
10 Shore Drive,
((If death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME .
Abraham
Davis
(If deceased is a married, widowed or divorced woman, give also maiden name.)
.. / (Was deceased a U/ m/ -X
| U. S. War Veteran, tMRs
V i f so specify WAR)
Lthri
Length of stay: In place of deat£l ..years months days. In place of residence... 2 lears months days.
(a) Residence. No .1.0. ShorC Drive St Wi.nthr.OP I
(Usual place of abode) (City or town and State) r
MEDICAL CERTIFICATE OF DEATH
3 DA
DEA
\TE OF C L R
SATH £ ,
(Month) (Day) /
(Day)
(\ ear)
4^31 HER E J! Y CERTIFY, That I ^ttended deceased from
. to • sZ/ , 19 6 7
I last saw h h-vt'1 ve on <■ ^T- , death is s
have occurred on the date stated above, at 0 ^.m.
8 SEX
9 COLOR
10 SINGLE
(write the word)
Male
White
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Married
said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) 0 M Q d /it. 5 / o .kvt
l$\.I£oRpAA&y.. ARXARY.
— /4^o.yf -2) r S S £ —
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
fC k^oti
Was autopsy performed? TiZo.
What test confirmed diagnosis
is>(J./ i H i* C <3. f...
5 Was disease or injury in any way related to
If so, ^pedfy
(Signature;
cupation^of d^c
M. D.
6 Pride of. Boston Woburn
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
2/ 6/.64
FUNERAL DIRECTOR Arn.Ol.d GolOV
address 1668 Beacon St Brookline ,
Received and filed
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowedwor
HUSBAND of
vorced
Cohen f
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
AGe6 7 Y ears Months 10. Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
Truck Driver
(Kind of work done during most of working life)
14 ordBus7ness Record - American
15 Social Security No. " on-Ql-95UT~
16 birthplace (City iCharle s town ,
(State or country)
Mass...
17 NAME OF
father Arron Davis
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Fannie CBL
20 BIRTHPLACE OF
MOTHER (City) . .
(State or country)
England
21 informants elma Shahon
46 Homestead
(Address)
St. Waban
'laSfe HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the buri*J?or transit permit was issued:
3k
• ■ C&SU
(Signature of Agent of board of Health or other)
(Official Designation)
(Date of Issue of Permit)
VJ:.
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION SZE-SZ-ZVC
DATE OF ENTERING MILITARY SERVICE G.©£.Z<P.*Z.
DATE OF DISCHARGE SLrr.flU..::. AfUfJ. K..k.y....Po&T. Ki.JP.JWA...jS.Ra.-£*X-
RANK, RATING L4/vAs..^^aI fT.e.^ C.iafc.f>£,r£f.e.£ A
ORGANIZATION AND OUTFIT zrfr.5*
SERVICE NUMBER i.3.Drr &
RULES OF PRACTICE
T 0; '■
:
i
r v
,ZV/-v
ixM
'<£finn
^0 —61964 f H ,
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.
*-30lA
I TIONS
B
•RTIFICATE
| vlng
p DEATH
enter
[an one
ir each
| and (c)
u not mean
1 of dying,
y.rt failure,
l|. It means
I or compli-
I ch caused
I, if any,
Be rise to
Iiee (a).
Be under-
Ire last.
||ir contrib-
U’.th but not
tie terminal
I ition given
lhapter 137,
1)4, requires
B to print or
I cause or
I death on
! ideates.
k
t
(County)
tr/zyrAz/pt/?
(City or Town)
(Enmmnmutfaltlj at HJaHHarljuapttH
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH Registered No
To be filed for burial permit
with Board of Health
or its Agent.
3a
d.m.WA WMl srvfG/A s., I <&t#tiSErtiU 5
' , / e ' /• DUVOTPTA V
hospital or institution,,
street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran, ...
if so specify WAR) A:.£..
2 FULL NAME. tL tkA£J>. _ , _
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. N o .XX . . . AZI. AAlA ZZ. AZ Z-— Si
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years... 3l.. months days. In place of residence t_£!T..years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
J~e.h .........
(Month)
(Day)'
if
(Year)
4 I HEREBY CER T/I F Y , That I attended deceased f
/ - / ?' ■ ,o 2 -f- r si
I last saw h I. •'Jive on / .. , 19.BB.T
have occurred on the date stated above, at ..W.» ....*? Q
8 SEX
9 COLOR
/14JLJF
death is said to
DEATH WAS CAUSED B^f: IMMEDIATE CAUSE
flmtnp 0 <s-rc m of
7?€C
(a)
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
■4/feA
Was autopsy performed?
What test confirmed diagnosis?..
5 Was disease or injury in any way related to occupation of deceased?
If so, specify.
Ox pjrms 3 eg tr/u et
Place of Burial or Cremation (City or Town) ,.\
s-
DATE OF BURIAL
FUNERAL DIRECTOR
t4'//v7~/ ^
ADDRESS rr
Received and filed '....Tl.Tr. i.....l.vT:
19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorced /■ k > • a a
HUSBAND oi AMA zxt CMd.iLtlJiL ASM.
(Give maiden name of wife in full)
(or) WIFE of _
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE YA?.. Years Months... Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
(Kind of work done during most of working life) ^
14 BALUAtzlLf
15 Social Security Ho.-
16 BIRTHPLACE (City).
(State or country) ZXXi
17 NAME OF
FATHER /6 4/FJ>
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
A/(A/?y (zs/z/ZAJi'A-zf )
20 BIRTHPLACE OF
MOTHER (City) — l£.£.MAZ>...
(State or country)
21
... ms me*
(Address) /O MAJPTA/VjU. ST H'/4TA/?£'0
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
/A? . yAzZZAA.ZkftfAL'0..)..
. /(Signature of ^Agent of Board of Heaith or other)
o£L^ 2,/ £>'/<?£</-
' ' (Date of issue of Permit)
.AStaVAJ r l % V fc , VuK. .
(Official Designatioi
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-
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, 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-si* 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 buned. 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, of when any person is found dead. — General
Laws, Chap. 38, Sec. 6., as amended t^y Chap. 1532, Sec. 4, Acts of 1945.
No undertaker or other persons phaH' 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'orits agent appointed To issue such permits, or
if there is no such board, from the Clerk otthe town where (he body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemeteiy or burial ground in whichith* interment is made.
. . . Chap. 1 1 4, Sec. 46. G. L.. (TeveWlfJanary Edition).
RULES' Oty PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice: _ .
(1) Attending physicians wiprertify tqauqk«daaths/>nly as those of persons
to whom they have given bedside£^qpirrfnf(ajg($iIl™M3 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 death»following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
- 1M R.S01
r burial permit
c d of Health
Agent.
l« CTIONI
IR
AdiiTincATi
R TYPE
l CAUSES
ATH
enter
tan one
or each
) and (e)
i not mean
od ol dylni,
art latlurt,
.It. It meant
ea or t ompli- .
ick touted
;<A, II any,
* lie rite to
t I are (a),
«f ir under-
i»>e tail.
ndimt contrib-
o Bi/A but nol '
to ke terminal
edition liven
luc,
i
i
1
I'octon
i ¥ i Mly
Clink.
62 JJUOU
OUT -
SUFFOLK
UJljp Qtammmuuraltlj of Jtttuifladjuflrttfl
(County)
lu- BOSTON
(City nr Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
BOSTON
(City or Town making thia return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
01289
No Nst.nchuantf* Cm*nI BAKER MEMORIAL
Marie Wagener,
((If death occurred in a hospital or institution,
..St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME R.®® J (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
8 Surfside Avenue, Winthrop, Massachusetts
tU. S. War Veteran,
if so specify WAR)..
(a) Residence. No St
(Usual place of abode)
..months Xlays. In place of residence. ^5ears. months days.
(City or town and State)
Length of stay: In place of death years..
MEDICAL CERTIFICATE OF DEATH
1 death*!!. Febma r.Y .6 , 196U
(Month) (Day) (Year)
FeltfrM fif X l&i\ brU^y'
_ piftii, dea
1? .2Qxpm
B| last saw^U.ahve on P Y .6 . I'6j[i, death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) JEJUNAL INFARCTION
I,u* T" OMENTAL HERNIA
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
GASTRIC ULCER
INTERVAL
BETWEEN
ONSET AND
OEATH
JkjnAi
LAY
h
Yes
WEEKS 16 BIRTH ’LACE (City).
(State or country)
Was autopsy performed?
What test confirmed diagnosis? Autopsy...
S Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature) .„. TT. *n..z\^mnK^.^d%nn^m i< , M. D.
CHorUa L. CU*. M.0L I
(Print or Type Name) '
(AddressiAaj'ufiLc., Mnaa. Gaa'LM**?. Dar? “6 “6 JL) 19.
6 Win.tM.PP. WintMo. p
Place ol lltirial or Creinatioit (City or Town)
DATE OF IIUKIAL
Feb, 10
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Howard S Reynolds
Winthrop Mass,4
Received and filed
f EBii ,bo4
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
V COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
divorced Single
UNKNOWN -1-*3
II II married, widowed, or divorced
HUSBAND ol
(Give maiden name of wife in full)
(or) WIFE of
ow 61
3
1
If under 24 hours
S AGE Years
Month**
.Days
Hours. Minutes
s“ Proprietor
(Kind of work done during most of i working life)
14 Industry
or Business :
15 Social Security No.
Resturant
UI9-^'113~
Germany.
17 NAME OF _ , ,,
father Jo haun Wegener
18 BIRTHPLACE OF
FATHER (City)
(Slate or country)
Germany
19 MAIDEN NAME
OF MOTHER
leather ine
20 BIRTHPLACE OF
MOTHER (City)
(Slate or country) Germany
21 I n lor muni . Elizabeth Bradford
8 Surfside Ave Winthrop
dard certificate of death
permit was issued:
(Official Designation)
>■ tr />odv hi
A TRUE COTA
\TTEST:
City iCcj4^a;ar
" r ' - V r
MAR - 0 fS6A Alt
RM R-301
or burial permit
ird of Health
s Agent.
SUCTIONS
OR
CERTIFICATE
T)R TYPE
: k CAUSES
TEATH
> it enter
rehan one
(■for each
)|o) and (c)
a i not mean
ot oj dying,
deart failure,
aytc. It meant
ea , or compli-
hick caused
itffl, if any,
ve rise to
sure (a),
he under-
luse last.
naons contrib- ^
o atk but not
tithe terminal
c dition given
i
-93L553
4
(Enmimmuiraltij of iilaBBarfjuflFttB
...Suffolk
(County)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Winthrop
(City or Town making this return)
..Winthrop
(City or Town)
No Bay View Nursing Home
STANDARD
CERTIFICATE OF DEATH
Registered No.
32
2 FULL NAME..
Mathilda Tornrose ( Lilliefors )
((If death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Wa:
i u. s
(.if so
as deceased a
War Veteran,
specify WAR)..
HQ,
(a) Residence. No. 6.4 Bates Avenue St .Winthrop
(Usual place of abode) (City or town and State)
Length of stay: In place of death years.. lQionths days. In place of residence 61 years months days.
MEDICAL CERTIFICATE OF DEATH
3{j£I?HOF February 7
(Month)
(Day)
1964..
(Year)
4 I H E R EBY CERTIFY, That I attended deceased from
Ocr* \9.SS to "I , i9.V*f
I last saw fii^alive on 19.. V»* eath is said to
have occurred on the date stated above, at ^.O......f#!.m.
8 SEX
9 COLOR
[female
white
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
\ % mo i c
(a)
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis? ...T-
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature
oV\* (*> t
Afl-O.
(Address)
, M. I).
OtSLfk..-
Name)
ate i9(aS^
6 Old Swedish 0 erne te ry , Wore e s t Q r
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ..F.e.
7 NAME OF
FUNERAL DIRECTOR]
address 174 Wintftr o p. S ffintnr o p ,
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (yrite the word)
MARRIEDWldOWed
WIDOWED
DIVORCED
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Idore Br or ..Tornrose
(Husband’s name in full)
12
AG
f88
Years..
Months.
8
Days
If under 24 hours
Hours Minutes
Occupation ... housework
(Kind of work done during most of working life)
14 Industry v.
or Business.. OWI1 hOIHS
15 Social Security No... [removed]
16 BIRTHPLACE (City).
(State or country)
Sweden
17 NAME OF
FATHER
Ola Lilliefors
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Sweden
19 MAIDEN NAME
OF MOTHER
Anna Marie Pearson
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Sweden
21 Informant ... Oliver W. Tornrose
(Address) 337 Washington St •Melrose
.. I HEREBY CERTIFY that a satisfactory standard certificate of death
Mass *i«f with me BEfORET.the burial or transit permit was issued:
(fignature of Agent of Board of Health or other)
h . /T. .9. . / .^. . ... . _ .
(Official Designation) (Date of Issue of I^-mit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
•••*•' *••*•••
4'. ;v, .
- . . .V,
RULES OF PRA 1 0 1964 fil
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
I R-301
ICTIONS
h
I ERTIFICATE
i ving
F DEATH
| enter
an one
jr each
) and (c)
not mean
of dying,
art lailure,
p. It means
or compli-
tch caused
i . ns contrib- .
• th but not
■ ie terminal
mition given
NChapter 137,
f JS4 requires
:i is to print or
t cause or
I f death on
c tificates, and
ti 4$, Acts of
r' uires Physi-
ti mint or type
Ji cr signature.
51 30213
Suffolk
(County)
/in.thr.o.p...
(City or Town)
©I j? (EommmiuiFaltlj nf iHaHHarijuartta
KEVIN H. WHITE
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
33
No.
0/^0 H - f (If death occurred in a hospital or institution,
..X.O.C.. Lj.X‘.O.iV!£.X‘.I3 kV..£..a. St. ) give its NAME instead of street and number)
2 FULL NAME rL-!r.
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
f(Was deceased a
. ( U. S. War Veteran,
[if so specify WAR) *.».Q
(a) Residence. No 208... GPO V.e T S A.Ve St.
Vinthrop
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death c/.Q. years months days. In place of residence ; r 3. years months days.
MEDICAL CERTIFICATE OF DEATH
deathjf V9 \3lHsX
(Month) * (Day) (Year)
4 1 HEREBY CERTIF Y # That I attended deceased from
19...\C?.!3i>, to ^ 19...W'T
I last saw h.V.fhalive on ^...^..l(...'>2..«i.<...sv..io...., i9-.Sc.St., death is said to
have occurred on the date stated above, at V.j&.i. m.
8 SEX
9 COLOR
10 CITIZEN
11 SINGLE |“|
OF U.S.
MARRIED El
Kale
.Vhite
YES NO □
WIDOWED □
DIVORCED □
UNKNOWN □
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) e jeV<UV> W><QVYV Vests
Due To
(b)
Due To
(c)
9~4V(1C ^ Sc-V 'g O z ’i 1
OTHER
SIGNIFICANT ►
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
a ^ ^
AGE...p..p...Years
Days
Was autopsy performed? MS.
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
M. D.
ed)
►X'V’V fife0®1* Name) 5
(Address) . . .OO's . > P. $ . ,**S «r.S.£ Date. . T.ffe.T? >P. 19*?..'^
6 ...Maple Hill Peabody.
Place ol Burial or Cremation (City or Town)
Re.h.r.uary. 11 l&l
DATE OF BURIAL
7 NAME OF ! ■ n -- T _ •
FUNERAL DIRECTOR IpU.! t.,.» L.PXi.O.S
address 42Q....Eary:ar.d LL.,,. Ir.Q.Q.kl.ln.a
Received and filed ‘.if |..i iSfj.r..
.19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11a If married, widowed, or divorced
husband of Esther. Sr.e.i.fcnL2L0..
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 DATE OF BIRTH
If under 24 hours
Hours Minutes
14 Usual
Occupation :
(Kind of work done during most of working life)
IS Industry
or Business:
Law
16 Social Security No.
17 BIRTHPLACE (City)
(State or country)
+2. vJ - LV.Sil... ~/..fc..»..
18 NAME OF
FATHER
Harris Kugell
19 BIRTHPLACE OF
FATHER (City) BuS.S.la..
(State or country)
20 MAIDEN NAME
OF MOTHER
Bluma Remestremsky
21 BIRTHPLACE OF
MOTHER (City) RUS-SX-cL
(State or country)
Informant
±.hax...,JLug.e.ll..
5=
(Address) poB trover's , ivo . lDblTrorT
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with ae BEFORE the burial or trapsit permit was issued:
(Signature of Agent of Board of Health or other)
Official Designa^fop) (Date of Issue of Pertnit) I
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING ...r
ORGANIZATION AND OUTFIT
SERVICE NUMBER
. yM.
V*-v u....
;-;V: .N r-3
RULES OF PRACTICE O /Or,„ - *,
> Vr/ “ A1 p ,/,/-•
The fulfillment of the purpose of these laws calls for the observance Of tbif
following rules of practice: ' . /TUljn? '
(1) Attending physician* will certify to such deaths only as those of person t-JJJ ' '
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-afp. .• p, inC/ pH
persons who, though disabled by recognized disease unrelated to any forr**(U I [3U ■ ’
injury, have died without recent medical attendance or whose physician fs w
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-301
>r burial permit
•d of Health
Agent.
1CTI0NS
0*
lERTIFICATE
)R TYPE
* CAUSES
EATH
t enter
r han one
for each
j) and (c)
s not mean
ol dying,
earl failure,
le. It means
or compli-
kick caused
Ir, if any,
ve rise to
fuse (a),
if he under-
-use last.
nd ons contrib- ^
oi ath but not
li ke terminal
Ci lit ion given
-6S933UOL
X
(Emnmnnuiniltii of fUaiiHarljuarttH
(County)
t.to'.mrmf./0
fr, (City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
2 FULL NAME..
(If
(City or Town making this return;
Registered No 31
Bjy Ml/ WtliMA SIMi'l U.W&S KSSitettXirJgSSSSi
/ / PHYSICIAN — IMPORTANT
/A./CRAM hA#M.X.. tlrAGAl 'AM.. ((Was deceased a
f deceased is a married, widowed or (\//orcz<\ woman, give also maiden name.) | U. S. War Veteran,
V i f so specify WAR)..
No,
// //
,.) Residence. No All (f lZZM/ . £*/// /? 0 S,.
(Usual place of abode)
Length of stay: In place of death years.. ^'months days. In place of residence iZ^years months days.
(City or town and State)
3 DATE OF
DEATH
ICAL CERTIFICATE OF DEATH
L
V (Monti
(Month)
J2^
(Day)
dm?
(Year) '
4—1 H E l{ E II Y CE R j I F Y_, That I attended deceased frotjt
4-1 HEREBY C
/DMA Af 19 6 A, to - 19
I last saw h.4..fSTive on . . p~r- , 19.6*" R death is said to
have occurred on the date stated above, at Q 7 /Qr.m.
d from
6/
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
J mi l * r> y. Ar **£<£.
(a) ...
Due To
(c)
PR
iNT 0. f Cc uP?.&. l/W D-S
OTHER
SIGNIFICANT
CONDITIONS^ irUl c p,x
INTERVAL
BETWEEN
ONSET AND
DEATH
IT-
1/D
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased W5
If so.
(Signature
ter:...., m. d.
(Address)
j.i2./?.4
' DPrint _a^2Iype Nrfnie) /
19..(r>.
^///.RR/ffR V... JR
Place of Burial or Cremation (City or Town)
DATE OF BURIAL /££.
.19.
FUNERAL DIR ECT< ) vA/f.AJP.R.. /... Q.R... /R./R/P/P^E..
ADDRESS /A A/VAA/AAP A R/... M A.AA.
Received and filed
Llt-A
(Registrar)
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FE/RUE
9 COLOR
A #/r£~
10 SINGLE (write the word)
MARRIED
WIDOWED
ES AU/P/P/ED
11 If married, widowed, or divorced
HUSBAND of x
(Give maiden name of wife in full)
(or) WIFE ofJkZf
(Husband’s name in full)
12
AGE
.Years Months
Days
If under 24 hours
Hours Minutes
11 s;:;.™,, , .MMK. MA/m C/?er//pM
(Kind of work done during most of i working life'
14 Industry
or Business:
f/t.M/E
IS Social Security No. A/SA.&...
16 BIRTHPLACE (City) /TA./.y
i Stale or country I /
17 NAME OF
FATHER ///-AGMSJ ^A/PAE)
18 BIRTHPLACE OF
FATHER (City)
(State or country)
/TA/~ L
19 MAIDEN NAME
OF MOTHER (? Efpy P 4M0/pjk
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
/ r */-
„ &1U3
4W e.rr^/r /■£' A’ d , r'C'/Yt'/
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
filed with me .BEFORfi the burial or transit permit was issued:
(Official Designatioi
tjt^ Heaitn ttr outer;
(Date of Issue of Permit)
.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the 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.
QIlj? (Snmmnmuraltlj of fHaBBarijuarttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Suffolk
]G (County)
p Winthrop VHW standard
fe (City or Town) CERTIFICATE OF DEATH Registered No.
S Winthrop Community Hospital
(City or Town making this return)
35
2 FULL NAME ,^.1®.1U -(.JfiCObS Oil
(If deceased is 3")narried, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
(Was deceased a
| U. S. War Veteran,
V i f so specify WAR)..
(a) Residence x ** 0 Trident Avenue,
(Usual place oi abode)
..St..
Length of stay: In place of death years months..*? days. In place of ie-niei.n X
Winthrop
(If nonresident, give city or town and State)
Jars months days.
MEDICAL CERTIFICATE OF DEATH
»iKIIuUF February 15 1964
(Month)
(Day)
(Year)
4 I H E R E B
I last saw leyhi.
Y CERTIFY . That I attended deceased , frop:
w£ .../fi b l 19 b?
8 SEX
9 COLOR
U) k rK
ve on
7<f b //. »if. death is said to
have occurred on the date stated above, at .. .y?./.. ■im,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
h >u <9 Vt ( /?vy-|rf tefrflg
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
/<W?.
Was autopsy performed?
What test confirmed diagnosis
5 Was disease or injury in any way related to occupation of deceased %
If so, specify
(Signature)
. , . (Print or Type Name) / /
(Address) 1$ 0
.fa/UkS*!. V'^aL tT
(City or Town)
/ .Jcfi
Place of Burial or Cremation
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
nu:
.far:. , . euu*
z
vr
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED ,
WlJJUWtU » • . _
divorcedM /WlR \ 6 p
UNKNOWN 111 ' 7
1 1 If married, widowed, or divorced
HUSBAND of
(or)
\ (Give maidenVname of wife m-fuil)
WIFE 0f..J.,.o.r>^?.hv
(Husband’s name in full)
12
AG
Years Months..
Days
()t'cupa,ion . ..(Mo O ."hr .frf
(Kind of work done during most worki
If under 24 hours
Hours Minutes
r
-
orking life)
14 Industry
Business: @fic>c r y f-efic
f
I
Social Security No... tVo
16 BIRTHPLACE
(State or country)
17 NAME OF
FATHER
iz v i ic tetri
■
-
r
r
18 BIRTHPLACE OF
FATHER (City)
(State or country)
/
a. a
f
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Uu,
21 Informant
(Address) ^ j ^ ^ ^ ^ ^ f3**tkl' * *-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFOREothe burial or transit permit was issued:
-
i * ’ (Signature of Agent of Bpard of Health or other)
(Official Designation) (Date of Issue of Permit)
A
A TRUE fOPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
AA
FEB 18 1964 *r
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.
* R-301A
TlCTIONS
§)R
a ERTIFICATE
1 living
<|if DEATH
1: enter
-Alan one
se or each
ilp) and (c)
It not mean
od oj dying,
;l art failure,
iA|c. It means
4a or compli-
I ich caused
•:e.
ij any,
rise to
use (a),
under-
use last.
ms contrib- .
.ith but not
to he terminal
edition given
:•* lapter 137,
£ 1 4. requires
i«i to print or
th< cause or
o death on
er icates, and
r I, Acts of
eq res Physi-
o jint or type
nd signature.
«ta9-925686
Suff oik
(County)
Winthrop
IU (City or Town)
U-lji’ CnmmDtiuTFalt^ nf HHaafiarlfiiartta
JOSEPH D WARD
SECRETARY OF THE COMMONWEALTH
it DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
No.
STANDARD
CERTIFICATE OF DEATH Registered No. 3B
(l)J vtJ~flJrnn C nruruusetj IdnslnJ tnJ f(If death occurred in a hospital or institution,
dJrLtUJTdlOp N04P-C XUL, S, \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
ts _ t-) i -p. f (Was deceased a
2 FULL NAME O.E.UC.e. a D£LD.y. . boy (U. S. War Veteran.
(If deceasen is a married, widowed or divorced woman, give also maiden name.) I if so specify WAR)
no
(a) Residence. No. 1.71 Fay wood Avenue, East Boston Mass.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years.
months
days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 deathof February 17
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, _ That I attended deceased from
19.64., i? Q i9. 6k
I last saw h A-.. TO. alive on )..!!?. 19.. death is said to
have occurred on the date stated above, at 5?..f^.....^T....m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Premature Separation of..
placenta
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
8 SEX
9 COLOR
in SINGLE (write the word)
MARRIED
WIDOWED AAjonJo
or DIVORCE I
male.
wkiXe,
10a If married, widowed, or divorced
HUSBAND of
(Give maiden
name of wife in full)
(or) WIFE of ...
( Husband’s
name in full)
11 IF STILLBORN, enter that fact here.
12
AGE Years
If*under 24 hours
13 Usual
Occupation : ...
Jdaxie —
(Kind of work done during most of working life)
14 Industry
or Business : .
Was autopsy performed? .... No
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify .. .. ..
^ T el m. D,
/V (PRINT OR TYPE SIGNATURE)
p.„ .e. - v j ) i»m
(Address
, Malden
Place of Burial or Cremation _ [(City or Town)
DATE OF BURIAL Jebm 20 ,, 64
Urincent Kapino
ADDRESS 9 C/vU*aa gotten
7 NAME OF
FUNERAL DIRECTOR
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
IS Social Security No.
Mona-
16 BIRTHPLACE (City)
(State or country)
flJirietkzop, Max- d,"
17 NAME OF
FATHER
Ppbestt firtuce
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
fio-iton
MguASs.
19 MAIDEN NAME
OF MOTHER
PcUaaxUxi XafierLLa
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Cotton
MOr iZ
21
Informant
( Address) .[oA
I HERF.B rcJER» a s'afisfo^tory* Sandard'*ceft’ff#ate 'of
was filed with me BEFORE burial or transit permit was issued:
kb. A
(J^igifature^of^Ageni of Board of Health or other)
(Official Designation//// (Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
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 giveThe text goes on. The rest is in the file.