The volume, 1965
Town Clerk, Winthrop · from the Internet Archive · 632 pages · 40.7 MB
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FORM R-301
e filed for burial permit
ith Board of Health
or iti Agent.
INSTRUCTIONS
FOR
EDICAL CERTIFICATE
RINT OR TYPE
USE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
f (a), (b) and (c)
This does not mean
mode of dying,
h as heart failure,
henia, etc. It means
disease, or compli-
ions which caused
ith.
Conditions, if any,
vhich gave rise to
ibove cause (a),
tating the under-
ying cause last.
Conditions contrib-
ng to death but not
i ted to the terminal
•ase condition given
(a).
PtMCL'a I
JAN - 5 1965
'M 2-62-932382
GImmttmtuiFaUij nf MaaHadjujsFttfl
Suffolk
(County)
Winthrop
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Winthrop, ;
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
fiTI Cl Vi 4 1 a,v Q4- J (If death occurred in a hospital or institution,
No^Z.n?..~! ~..¥. St. j give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name E.dw.ar.dL H... Haley
(If deceased is a married, widowed or divorced woman, give also maiden name.)
) (Was deceased a LIIJ
J U. S. War Veteran, ’* ”
V i f so specify WAR)
(a) Residence. No.8.31 Shirley St.,. St M ASS
(Usual place of abode) (If nonresident, give city o/ town and State)
Length of stay: In place of death~!:..P..years months days. In place of residence5Q~years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
...January 2, 19.6.5.
(Month) (Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Q..fJr. 19..1b^ .. to \\ 19.V**
I last saw h*..4tlive on .. .3*4 -a-. 19....t.,'^eath is said to
have occurred on the date stated above, at M.Jl.^.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
ts \>A > cA v y\ LcL<cA vCi SA
(a)
(b^e...1.(XK..Vr^.^...V.v.4..cVe..»r.u.A.<.t...\#»trV..Av5r.&A5 S'
Due To
(c)
OTHER rs ,
SIGNIFICANT YA. Si *
CONDITIONS TTcT. \y\t
T _ II
Was autopsy performed?
What test confirmed diagnosis ?
.€...S..l.L^...^....\v.e....«sr!(...V...
EL
INTERVAL
BETWEEN
ONSET AND
DEATH
A £ WW
5 Was disease or injury in any way related tcx occupation of deceased?
If so, specify A, MJ .sr .tCii-
(Address)
(Signature) ^
^-T'-VS
6 Winthrop Cemetery Winthrop Ma s s
Place of Burial or Cremation (City or Town)
DATE OF BURIAL January. 5* ,.,6.5...
7 FUNERAL DIRECTOR 6?. 6.6 ^T. *L?. Q..!.Mpl P y
address Wint.hr.ppj Mass.
Received and fi
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WID0U;E$arried
DIVORCI
UNKNOWN
1 1 If married, widowed, or divorced
husband of Agnes Cronin
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE
58
Years Months..
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
Real Estate Broker
(Kind of work done during most working life)
14 Industry
or Business:
Real Estate
15 Social Security No. . ,
16 birthplace (City) Manche s t er
(State or country)
Mas s
17 NAME OF
FATHER
Edward H. Haley
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Swamp scott
Mass
19 MAIDEN NAME
of mother Catherine Coyne
20 BIRTHPLACE OF _ , , _
mother (City) So uth ...Boston
Mass
(State or country)
21 informant Agnes Haley
(Address)
831 Shirley St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed
ed wjth jnt, BEFORE the- burial or transit permit was issued:
C}< ft) ....._
* ic.. •*. . 7 - 0f Health or other)
r ■'/):. 1 . ofKgent ol
,
(Official Designation)
Jr/.£.s£
ie of Issue of Termit)
A TRUE COPY ATTEST:
, -•
Ik
V
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE 10.r.l3-^.2
DATE OF DISCHARGE .U.t.2.6.tA5
RANK, RATING Lieutenant
ORGANIZATION AND OUTFIT LLS.ULR.
SERVICE NUMBER 2Q.8868
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 la6t 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-5P55
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- f
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
IM R-301 A
ISTRUCTIONS
FOR
CAL CERTIFICATE
In giving
5E OF DEATH
lo not enter
ore than one
tuse for each
a), (b) and (c)
hi. t does not mean
mode of dying,
as heart failure,
nia, etc. It means
iscase, or compli-
es which caused
editions, if any,
ch gave rise to
vc cause (a),
•in it the under-
ig cause last.
onditions contrib-
to death but not
'd to the terminal
sc condition given
).
)te:- Chapter 137,
: of 1954, requires
j sicians to print or
the cause or
es of death on
h certificates.
m. e.
AN - 5 196$
Suffolk
(County)
Winthrop
(City or Town)
®ljr (Enmmomuraltl] flf fHaaaarljuarttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
2 FULL NAME..
STANDARD
CERTIFICATE OF DEATH Registered No 1£l
n i f f Hnpco MllY*R'1n£7 HfimP ((If death occurred in a hospital or institution.,
Carl G Wilson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Residence. No .4?. Wald ema r A v« . ,
(Usual place of abode)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a)
Length of stay: In place of death years months. 14 days. In place of residence, y.-^ years months days.
65.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
(Month)
...a..*
(Day)
i...£A.$:
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
//" 0 v » , 19 to ..J ....ft...w.s. 3*, , i9..4.i...
I last saw h LYvtilive on S...SS&. !?r-....k. , 19..6. S , death is said to
have occurred on the date stated above, at £J..m.
INTERVAL
BETWEEN
ONSET AND
DEATH
(o Vu os,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) J ■AA.h.0.S...L.Sy Q.'ir.
V
Due To
d» -
Due To
(c) - ~ -
SIGNIFICANT
3 LJ ri 1
CONDITIONS / / 1
Was autopsy performed? _.iY..A2. j
What test confirmed diagnosis? .£L.1..I...UL..v S..Q-....1 -
5 Was disease or injury in any way related to occupation of deceased
If so, specify.
(Signed) M. D.
(AddressltO...\_VL.?i.\/vYr.iU..\9j.— ^l(l--9'-SL*S...Date..2!^.4i.1d.*..^tTr.....l9..^..
*
6 ...Winthrop
Place of Burial or Cremation
DATE OF BURIAL
Winthrop
(City or Town)
Jan, 5,
19.65..
7 NAME OF
FUNERAL DIRECTOR
Howard.. .S... Reynolds.
address winthrop, Mass.,
Received and filed 19..
(Registrar)
8 SEX
| 9 COLOR
Male
| White
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCE
ingle
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..
.4...
Months.._..V...Days
If under 24 hours
Hours Minutes
13 usua! Maintenance
Occupation :
(Kind of work done during most of working life)
14 iJ<"ffi......Ford Kotor Co.
15 Social Security No..
16 BIRTHPLACE (City).
(State or country) MflSS
025-^9-5780
East Boston
17 NAME OF
FATHER
Charles Wilson
18 BIRTHPLACE OF
FATHER (City)
(State or country)JjQ X*WRy
19 MAIDEN NAME
of mother Emma Anderson
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Sweafd
.en
21
Informant Madeline Birkmaier
(Address) 49 Waldemar Ave. '.’inthrop,
I HEREBY CERTIFY that a satisfactory standard certificate of death
filed with me BEFORE the burial op transit permit was issued:
waj filed with me Iih.ft3Kk. the hurial op transi
/(Signature af Agent of Board of- Health or other)
(A o' /U -T
(Date of Issue of Permit)
U-
on
(Official Designation
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-six and forty-seven
of said chapter one hundred and fourteen, the word "war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. by a satisfactory certificate of the attending physician, if any. as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if. for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal ; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114. Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. —General
Laws. Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemeteiy or burial ground in which the interment is made.
. . . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death.— Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done 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, efc. For_ ■
a person who had no occupation whatever write none. ^ “ I 'J , ,
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT . ..
SERVICE NUMBER..
FORM R-301
K
C
led for burial permit*
Board of Health 3
or its Agent.
INSTRUCTIONS
FOR
CAL CERTIFICATE
ft
3
NT OR TYPE
E OR CAUSES
'F DEATH
lo not enter
ore than one
use for each
s). (b) and (c)
•0
$
t does not mean
node o) dying,
as heart failure,
ia, etc. It means
sease, or compli- .
r which caused
dilions, if any,
:h gave rise to
le cause (a),
in* the under-
g cause last.
onditions contrib-
to death but not
to the terminal ;4j
condition given ^
VC.
)<»; \
N - 5 1965
-63-93631+8
<
ultjr (Cmnmmtumiltlj nf fHasHar^uaFtla
12 Suffolk
P (County)
Minthrop
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
: 3
Registered No.
((If death occurred in a hospital or institution.
No .W.in.t.hmp Community Hospital St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name H.athan Zeidel
(If deceased is a married, widowed or divorced woman, give also maiden name.)
..) (Was deceased a j
\ U. S. War Veteran, * /
V if so specify WAR) cS/. -.i
(a) Permanent Residence. No.
(Usual place of abode)
i 5.0. Cutler. St.,., st
l+h hrs 7
Length of stay: In place of death years months days. In place of restden^J(L/.. years months days
Winthrqp, jqass.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Month)
3 f Jj A
(Day) (Year)
(Year)
A I HEREBY CERTIFY
19.
I last saw h./.^live on
have occurred on the date stated above, at
E R T 1 F Y , That I attended deceased, frpn
6.y ,o // 3 - .9,45:..
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
4 /kk7£
Due To
(b)
.££ft..£7 W.L
Due To friv b faTM/oSCL&LCT/*
(c) yfr/3
OTHER Ush/f
significant ly..y..r...rr
CONDITIONS
Was autopsy performed? (I*
What test confirmed diagnosis? kUMCtly
INTERVAL
BETWEEN
ONSET AND
//< t
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature)
})
M. D.
(Address)
...^T..... (A.slyi).......
772/^veS sJLoll
Placef of Burial or Cremation j (City or Town) Vr*
(d
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed 19..
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Ask
9 COLOR
ITtfL
10 SINGLE (write the word)
MARRIED ,
»wc!S/H^2^0
UNKNOWN
11 If married, widowed. oOlivorced^ _ _ . ,
HUSBAND of aWiaUDlT .
(Give maiden name of wife in full) >
(or) WIFE of..
(Husband’s name in full)
Years.. fTT. Months
Days
If under 24 hours
Hours .^Minutes
Occupation L*6jh.£.fL £..T. J 1 .& K *<£
(Kind of work done during most of working life)
14 Industry
or Business.
15 Social Security No.. a.i 'a Q.kr.LS.
16 BIRTHPLACE (City).
(State or country)
^ ' NS U
€C>
Kuy* lQ.
17 NAME OF
FATHER
18 BIRTHPLACE OF av _ j
FATHER (City) I.Z\....I...Q ’b.Pr-r-)
(State or country) f\ O S / c?
id C (
19 MAIDEN NAME
OF MOTHER
0 £>L.
20 BIRTHPLACE OF
MOTHER
(State or
PLACE OF hj /
5R (City) .r^jyi...L t]...4A
or country) —he U &■ •£ ) 3
AeaTnuQt /ver,q
... 5" o ti-.tiTj S t (,OsCn.tl\,T., p
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:
(Signature of Agent of Board of Health or other)
yji 1/
(Official Designation)
(Date of Issue of Permit)
It
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
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.
'< ij
t l '
Statement of Occupation.— Precise statement of occupation is very impor- J/- — - ~ (r’Aj-
tant, so that the relative healthfulness of various pursuits can be known. Make . * u CJ 1
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
FORM R-302
w
; >
o
X
to QJ
a *
< H
U 2
v> a
D 2
*su
2 «
u 50
o" -
Ws
*. 4)
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Sxot
X.u .
II-
73 >'•
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73 O o;
.- *• 4>
»bS
u O
„ u u
OJ 3
o 0> y
0>X O
~ rJ
X o>
*> j-*a
c —
* 2-P
O 2
«
w
2 a,
* £
'M r-
o c
* ^
U C/3
< -
*-3 co
M 2
Sj«-S
•CEo
u O k
2 to «
to B "
C O'**
o
u ~ O
3 £*0
o V)
« c_£
O CTJ •“
X ~ u
<u
•" 4> ■»-
X .O'—
£ «
•a .
€is
«» a
**-•£ Q*
2°S
%»>
*?.§ 2
— £*o
a*- —
©fj? (Emnmmuuraltff nf fUafiaadjuHFttH
S ^
lZS.Hl.dLdle.ssx rJ9
(County)
(to
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
...W.ayla.nd t
(City or Town making this return)
COPY OF
CERTIFICATE OF DEATH
Way land
y (City or Town)
£ No..Ka.t.hr.yn Ba.nt.Qn Nursing Homs.
Registered No.
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME
Hs.r.b.e.r..t Dwight Hall , /^Is
if s
(If deceased is a married, widowed or divorced woman, give also maiden name.)
S. War Veteran,
so specify WAR)..
(a) Permanent Residence. No 2.?A P.l.e.a S ant S. WinthTOfi
(Usual place of abode)
Length of stay: In place of death j: ..years ...§ ....months^. days. In place of residence..~lUyears months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
.January. 6..., 194
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
Apr.ll X 19.6.3. to January .6 1 9.6.5
I last saw hllBlive on ..JUH* 3 19..6..5 death is said to
have occurred on the date stated above, at 6:.2.5-.a.. .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .Pneumonia
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
1 rr.cnt 1 age..9.1. Years 2..Months...J) Days
Was autopsy performed? 1.I..Q
What test confirmed diagnosis? .G.lini.c.al..
5 Was disease or injury in any way related to occupation of deceased^ *, ...
If so, specify 1)1.0.
(Signature) L.Q.LliS LI* EL&S.Xli.Zl M. D.
(Address) Il.9;£..£L* Date
6 .W.in.t.hr.o.p, W.ln.t.hr..Q.p.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL January. .9. w ...6.5.
7 funeral director Howard. 2L Reynolds..
address Wint.jan.Qp. Hags..,
Received and filed
JAN 121965
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRI/EEiWidowed
WIDOW
DIVORCED
UNKNOWN
11 If married, widowed, or, divorced
husband of Label Bigelow.
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
If under 24 hours
Hours Minutes
13 Usual
Occupation : ... Yl C .gL. P £ .g S..1 .&§ U t
(Kind of work done during most of working life)
H or ^Business : I US U ra.n.Ce C.Q..t
15 Social Security No....Q.2AL~.Q.
17 NAME OF
father Henry E. Hall
18 BIRTHPLACE OF
FATHER (City) .sP..p.e.n.G.ei?
(State or country) L as g .
19 MAIDEN NAME
of mother Hattie J? . Gordon
20 BIRTHPLACE OF
MOTHER (City) .P.Q.Y.©.£
(State or country) UeW HaiflpShiPe
21 Informant ..L.QUj.S ClOUtier
(Address) Burl ingt.Q.n , Mass..
A TRUE COPY
ATTEST
n
/\&('<% ,J C&,i5t .Clerk..
(Registrar of City or Tdwn where death occurred)
i6 birthplace (cuy). . w..Qr..c.e.s.t.er..r . ..
(Stale or country) ilcl F 0 "
DATE
filed January. 1.1., 196.5. v |
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
:0
'Jj
\_y
UJ
♦jr:
'CO
2
:;e*
i
L
led for burial permit
Board of Health
^r its Agent.
FORM R-301
ISTRUCTIOHS
FOR
:*L CERTIFICATE
VT OR TYPE
E OR CAUSES
F DEATH
o not enter
are than one
use for each
0, (b) and (c)
i does not mean
node of dying,
aj heart failure,
ia, etc. It means
sease, or compli-
i which caused
ditions, if any,
:h gave rise to
le cause (a),
ing the under-
g cause last.
onditions contrib-
to death but not '
I to the terminal
• condition given
M.C.
kc '» f
12-62-934553
QIljp (Efltnmmuuraltlj nf m&aaaartjuflFttfl
Suffolk
(County)
... Wint.hro.p
/( j (City or Town)
<
I J
\p.
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return) '*
STANDARD
CERTIFICATE OF DEATH
Registered No.
jSl
-tr • {(If death occurred in a hospital or institution,
ci.y. y.l.S..W.....iVU2^S.lTlg... ..TlOIIlS St. ( give Its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name Nellie. Chamberlin Cr ocker ?,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
j (Was
| U. S.
\if so
as deceased a
War Veteran,
specify WAR)..
NO.
(a) Residence. No 1.0. Sfi.ay.itLW. AYfiXMfi St.
(Usual place of abode)
(City or town and State)
Length of stay: In place of death..G....years ^.months days. In place of residence...!.^) ears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
IT
(Month)
i j...
( Day )
zei
o
(Year)
4 I HEREBY C E.R T I F Y , ,That 1 attended deceased from
i9sfcaL., to .10/T.k. .0 1®?.X
I last saw h.C??alive on 7. , 19 ...y.J^ death_ is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
f±
Due To
(c)
£ err-' <m/h c f t /
OTHER
SIGNIFICANT
CONDITIONS
ju rmo'rtzf.
j. r
Was autopsy performed? /V....W .....
What test confirmed diagnosis?
INTERVAL
BETWEEN
ONSET AND
DEATH
id fin
2ML
4W
5 Was disease or injury in any way related to occupation of decease;
If so, specify
fifz
(Signature)
M. D.
(Print or Type Name) in , '
(Address)/^yi^rr../t?k/?.i?.y..).^^'.^.../. i/loate L..I......I... 19.S.7?..
;.fr l /v
^T
6 ..Hope. Cemetery. .l.Qr.c.e.s..t.er.,.M.as s
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ... Januar;
7 NAME OF
FUNERAL DIRECTO
address 1.7..4. .Win^hr-Qp. St... Iln..t.h.r op ,
Received and filed
JAN-81965
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Hemal e
9 COLOR
white
10 SINGLE (wfita the word
MARRIED widowed
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of . Er.e.der.i.ck... X. Crocker..
(Husband’s name in full)
12
AGE..Q.2. Years. ...Q. . 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 0WI1 1101116
15 Social Security No. Oig-u?-4W5"
16 birthplace (City) „orcesier
(State or country I T.'TaS S SCUUS e 1 1 S
17 NAME OF
father Clarence Eustace Chamber-
18 BIRTHPLACE OF
father (City) Thorndike.
TTn
(State or country) R nhl3R ft t, t S
19 MAIDEN NAME
OF MOTHER
Anna Sophia Greene
20 BIRTHPLACE OF
MOTHER (City) MO.nS.On -
(State or country) T.^.S S H.^hUS e 1 1 S
’21 Informant .Mrs.., Joseph ...S , Berry
(Address) .10. Seaview Avenue, ..Winthrop..
TiT I HEREBY CERTIFY that a satisfactory standard certificate of death
MUSaS Wed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
(signa
.RuM.
^ :^rV. . .^/. .. . . . .
(Official Designation) (Date of Issue of Permit)
d'dzRtfL dr/f* c ^ i/i
W
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TO',i.
JAN - 8
AH
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
M R-303
ed for burial permit
Board of Health
r its Agent.
2 U. *• W
-O jS
jjoS(3 £
•-Id'-' fl
bl
JfX
< «s|5
j
u U^r
*Z-=2
o< S „
U « ^
Ulldu^
-I “=>«§■
J £515
C S.«o
< 2 fc -
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Us « .
ft. 0 X ao
“"X «- «
<"fcd
(0
BU
U1 3U
5 22-po
■ »2 * •
< ?ss-
y i S s j
3 *2-2*
~d-*i
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/) “S H.s
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j §■»!!
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d :
s *■ °
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3 >u 5 “
< .* t S
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ft. © —
y u'ilx£
^ t 2
H “•Su0
H ifc.EQo
I
D «
2
T3
47 CO
£ •£?
SUFFOLK
(County)
WINTHROP
(City or Town)
®f)t Commontsraltl) of iflaggacbugetta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER'S
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No. (J
No.
2 FULL NAME
I. rhanloo Q+ Winihnnn ((If death occurred in a hospital or institution,
i. ...Q. . Tf.“T. „ .~r.T~ *.Jt St. I give its NAME instead of street and number)
ROBERT />A (S/U MURRAY
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
(W as deceased a
U. S. War Veteran. a/s?
if so specify WAR)
(a) Permanent Residence. No.
(Usual place of abode)
4 Charles St., Winthrop St
Length of stay: In place of death years.... £ ..months lays. In place of resid
(If nonresident, give city or town and State)
1/ /U
months..././.. ..da vs.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ...
January 7.j
(Month) (Day)
1965
dear)
9 SEX
41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
10 COLOR
(write the word) —
11 SINGLE
MARRIED
WIDOWED
DIVORCED 0 _ . d-
UNKNOWN V
are as follows: (If an injury was involved, state fully.)
Acute interstitial pneumonitis with
pulmonary edema,
12 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
sband’s name in full)
during most of working life)
-rjwfs /f7
fT fiF ~r„ . _ . . ^ f
19 BIRTHPLACE OF A. . r
FATHER (City) fcAAT^AAt.....
(State or country) yy S S
20 MAIDEN NAME
OF MOTHER fA/f/c/A AW*' /Y/s-iry
p , (Print or IWp^lame)
(Address) Vl. Date
21 BIRTHPLACE OF ^
MOTHER (City) <S..f 7A.A..AA1...
(State or country) 5_S
7
Place of Burial or Cremation. (City or Town)
Informant iTAMlA
(Address) y
DATE OF BURIAL
£ S'T mrw**
, ,, . . JL , y yy y _ - I HEREBY CERTIFY that a satisfactory standard c(
FUNERAL DIRECTOR A?AA..A./A.Al...
ADDRESS ..AA/.6/..A/AAAA..S.. '
isfactory standard certificate of death
was filed with me BEFORE the burial -or transit permit was issued:
If under 24 hours
Hours Minutes
f
Received and filed
A TRUE "COPY" ATTEST:’
JAN -8
(Registrar)
^
Official Designaaqft) (Date of Issue of Permi
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 rule^£p$ practice:;] [ u
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside
care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by
recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only
deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical
(drugs or poison) .thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting
from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those
of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under
cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with
the circumstances when these are known. For example: “Compound fracture of the femur with ensuing septicemia
(gas bacillus) caused by a collision of railroad train and automobile.” “Pistol shot wound of the chest with associated
hemorrhage, homicidal.” “Asphyxiation by suspension, suicidal.” “Syncope while under the influence of ether administered
as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery).” “Fracture of the skull
with associated internal injury sustained under circumstances unknown.”
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease,
specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to
medico-legal inquiry. For example: “Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed).”
“Heart disease, presumably coronary sclerosis. (Sudden death.)”
r
FORM R-301
. To be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode 0 / dying,
such as heart lailure,
asthenia, etc. It means
the disease, or compli - ^
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given
in (a).
no
100M-5-64-938000
.Tf y OWT CttnmmonuiMltly of fHaoBar^uorllfl
a'1 1 - ( ^ KEVIN H. WHITE
Suffolk
(County)
7
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this ret
<)04(
Registered No.
Boston
(City or Town)
N„ Mew England Center Hospital s,
PHYSICIAN — IMPORTANT
2 FULL /(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran*
\jf so specify WAR
fflw # 1.
(a) Permanent Residence. No. l8l....BartleM....EQa,ci St Winthrop,. ....Mass..
(City or town and State)
Length of stay: In place of death years months....^.. .days. In place of residence^O . years months days.
MEDICAL CERTIFICATE OF DEATH
death0. January. 11, 19.65
(Month) (Day) (Year)
4 1 HEREBY CERTIFY, That 1 attended deceased from
January. Z, i9....o5 to January 11 n...6$...
I last saw hjLniJive on January.. 11...., i9. 65. death is said to
8 SEN
9 COLOR
10 SINGLE (write the w<
Male
White
MARRIED
wmowF.DMarr ie<
DIVORCED1 iai 1
UNKNOWN
have occurred on the date stated above, at . 12.15am
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
ok m yv { /^t>//9 /s'F/vkcT.
3
(c)e fr>T)Ps/l/JE7?7Al
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
/ AG 66 .Years Months Days
/»<**//
</£7fcS
Was autopsy performed? A)(>. „
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature)
<£?.;, M. D.
!^9...:.
(Print °^yr5'P* Name) / i
rW •...sJ^VTVT^....\)a\e. .iy/Z^. 19 A5
6 Wln.thr.o.p. .Winthr op..
Place of Burial or Cremation (City or Town)
DATE OF BURIAL January. 1.4, ,6.5.
7 funeral director Arthur J..+ Q...!..Mal.ey .
address Winthr Op, Mass..
Received and filed
/ •
JAW i o 1955
/> *
-r-'ft
27
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, \v
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
If under 24 hours
Hours Minuti
13 Ka, ion. Proprietor
(Kind of work done during most of working life)
M or business:. WOOl BUS inCSS
15 Social Security No. [removed]"
is birth i’i.ace (City i Waltham,
(State or country)
Mass
17 NAME OF
father Lewis W. Franklin
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Natick
Mass
19 MAIDEN NAME
of mother Belle V. Tarbox
20 BIRTHPLACE OF . ,
mother (City) Far ni ington
Maine
(State or country)
21 Informant Josephine Franklin \
181 Bartlett Road Winthrc
(Address)
A I HEREBY^ CERTIFY that a satisfactory standard ceyyScate of
/] s fijet^ wo)h nV II I I Oil’- iln burial or transit pertj’fy was issu
taltltir other)
(OfirciarDesignationV (Date of Issue of Permgr) '
A TRUE COPY ATTEST:
-
i
FORM R-301
ed for burial permit
Board of Health
br its Agent.
ISTRUCTIONS
FOR
:*L CERTIFICATE
VT OR TYPE
E OR CAUSES
F DEATH
o not enter
ore than one
use for each
»), (b) and (c)
r does not mean
node of dying,
as heart failure,
ia, etc. It means
sease, or compli- ^
i which caused
ditions, if any,
:h gave rise to
le cause (a),
ing the under-
g cause last.
onditions contrib-
to death but not '
I to the terminal
condition given
9-63-93631*8
JHT
(County)
Z/Zz/AZ^/d^...
(City or Town)
(Smnttumuiraltfj of fUariHadjufirttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
8
2 FULL
name A.6.£.d.<y..e.£.
(If deceased is a married, widowed or divorced woman, give also maiden nameO
f (If death occurred in a hospital or institution,
| give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
.. j (Was
) U. S.
Lif so
as deceased a
War Veteran,
specify WARi.....^..,.
eo ox? 7 jSA .<■
)^ _
Length of stay: In place of death...^.... .years months days. In place of residence^.byears months days.
(a) Permanent Residence. No.
(Usual place of abode)
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January
(Month)
..1.6.* 1965
(Day) (Year)
4 I HEREBY CERTIFY, That 1 attended deceased from
...March 5 „ 19&.0 to Jan. 1.6... 19 65
1 last saw e.r alive on .... Jan.. 1.4* ..., l'&.S, death is said to
have occurred on the date stated above, at6 £ 15 3 *1. INTERVAL
BETWEEN
ONSET AND
DEATH
2 wks ,
8 SEX
9 COLOR
/t/z/rz
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cerebral thrombosis with
(a) r1_ght hemiplegia
Due To Arteriosclerotic a$d
(b) hypertensive heart disease
Due T° Generalized arterio-
(c)
sclerosis
OTHER
SIGNIFICANT
CONDITIONS
12 r
If under 24 hours
, AGE^.j^TTYears
Months
Days
Hours Minutes
lOyrs
L5 yrii
Was autopsy performed? ..
no
What test confirmed diagnosis1
C jL .e3w.lwl.fJw .Cf. .S. .if
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature) \
^ M. D.
ffiW&fZteTRT Jr'.'T
(Address) 73. ^0.18,, Ǥ
Wiht hr bp , Mass. — 02152
/Z./ZZ.Ctf/!d..#/>
Place of Burial or Cremation (City or Town)
DATE OF BURIAL yT../?../Z.. Z.f... 19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
tyJZA Md..
Received and filed .. JAM 19
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED / . /A . ,t /'-/)
UNKNOWN (Z //) & CAZ Z
~jZ.
11 If married, widowed, or divorced
HUSBAND of /.< H C\/L; f- .
.. (Give maiden name of wife in full)
(or) wife of .AMAr.a..Ad.. £^Jk&L j
(Husband’s name in full)
13 Usual
Occupation.
AA.z±£...zwji£&.
(Kind of work done during most of working life)
14 Industry // . /
or Business (...^7..
15 Social Security No
16 BIRTHPLACE (City) \ ^ A ZZ'.A'j./-
(State or country)
Z
17 NAME OF r
FATHER /, q
18 BIRTHPLACE OF
FATHER (City)
(State or country)
/ Z//QO. jf ) CRc'Vi/ht.
../Z.z.7... /ZmcZzaL
19 MAIDEN NAME
OF MOTHER
/* O T Jd/ZZ/Z/C
20 BIRTHPLACE OF . / ,
MOTHER (City) ZlZ-.-Z llACZ./U..<
(State or country)
« yjycy SfrsMS
(Address)
A TRUE COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
(/3J
(Signature of Agent of Board of Health or other)
(Date of issue of Permit)
(Official Designation)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
rdhte'ofL'r
he
The fulfillment of the purpose of these laws calls for the obser
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.
1235
fH
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
ed for burial permit
Board of Health
r its Agent.
ISTRUCTIONS
FOR
SAL CERTIFICATE
•IT OR TYPE
E OR CAUSES
F DEATH
|o not enter
>re than one
jse for each
.), (b) and (c)
does not mean
tode of dying,
is heart failure,
a, etc. It means
tease, or compli-
which caused
litions, if any,
h gave rise to
e cause (a),
ng the under-
’ cause last.
mditions contrib- ,
to death but not
to the terminal
condition given
W[,C
2-62-932382
Suffolk
(County)
0% QlmttmmiumiltJj of fSaHBarijuorttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
X
H
<
Iw,
o Winthrop
3 (City or Town)
/-it • it . „ _ n._„ } tit aeatn occurrea in a nospital or institution,
No. V.l 1 ll.Q.USe WT . S lug Home St. I give its NAME instead of street and number)
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH Registered No Q.
((If death occurred in a hospital or institution,
PHYSICIAN — IMPORTANT
2 full name Delia A.* D.QM
(If deceased is a married, widowed or divorced woman, give also maiden name.)
..) (Was deceased
) U. S. War Vete
t,if so specify W
Veteran,
ART.
No
(a) Residence. No 3-62 ■Silil'.lfi.y St ^ St..
(Usual place of abode)
xk days. In place of residence.6.Q.ye
(If nonresident, give city or town and State)
Length of stay: In place of death years months±-..*Tdays. In place of residence.)^. V.years months days.
MEDICAL CERTIFICATE OF DEATH
3 Seath!. January 17, 1963
(Month)
(Day)
(Year)
4 I H F. R EBY CERTIFY ,^That I attended deceased front
.^J.OLM. 19j£&.., to *T..../\..A/. LJL 19.£.£l
I last saw h^I^live on ./ 7. 19.X2.J, death is said to
have occurred on the date stated above, at m.
D
(a)
WAS CAUSED BY: IMMEDIATE CAUSE
.^M..6.M.H4.o...M..La...y. Am.hj
\ 1 \ Y Ci ( ^
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis
5 Was disease or injury in any way related to occupation of deceased ?/y. a
If so, specify yx.......
(Signature)
M. D.
...&J4A...l3.L£s UL&..£...RA4^.A
, . (%int/V Type Name) / / y ^ <
(Address) (X/././ty,/, f\ .{). PyM4S$> ate 19..6..SJ ^
Winthrop
Winthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL OST .X 1.9. 19.6.5,
7 NAME OF . , , — - /-. « */i t
funeral director Arthur J,. .0,,,Ma.l.ey
ADDRESS
Winthrop, Mass
Received and filed
JAN 1 8 1965
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
divorceW i d.o we d
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
i.i n i t~ a v» T?
(or) WIFE of..
_ , (OivemaidetLname
Walter E. Daw
(Husband’s name in full)
AG
e8.9-
Years Months..
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: HO.USCW.if.ft
(Kind of work done during most working life)
14 Industry
or Business: OWH liOHie
15 Social Security No,
16 BIRTHPLACE (City),
(State or country)
Melrose
Mass
17 NAME OF
FATHER
Thomas Cassell
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
of mother Bridget Hanrahan
20 BIRTHPLACE OF
MOTHER (City),,
(State or country)
Melrose
Mass
21 Informant B.OhCr.t T. DSW
(Address)
362 Shirley St., Winthrop,
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
oPfeb-s £ )
(Signature of Agent of Board of Health or other)
fLtS&Mti*.
(Date of Issue of Permit) y
(Official Designation)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
V- ‘-''y, ci
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 —
note!, etc. For a person who had no occupation whatever write none.
So
FORM R-301
ed for burial permit
Board of Health
r its Agent.
STRUCTIONS
FOR
AL CERTIFICATE
IT OR TYPE
IE OR CAUSES
DEATH
not enter
Ire than one
jse for each
). (b) and (c)
does not mean
tode o) dying,
u heart failure,
a, etc. It means
tease, or compli-
which caused
lit ions, if any,
h gave rise to
e cause (a),
ng the under-
’ cause last.
mditions contrib- .
to death but not
to the terminal
condition given
^-63-93631*8
(fmmnmuuraltl) nf fHaflaarfyufleltfl
[< SUFFOLK Y\ <3-' | [ SECRETARY OF THE COMMONWEALTH
M h* (City or Town making this return)
10
2 FULL NAME..
(County) (tLy In DIVISION OF VITAL STATISTICS
VINIHROP Ijt STANDARD
(City or Town) CERTIFICATE OF DEATH Reg.stered Nor
"IL rfiRUP COiPiUl.ITY tOSPITAL ((If death occurred in a hospital or institution,
No St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
PEARL WEINSTEIN (Cohen)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
) U. S. War Veteran,
\if so specify WARi No
(a) Permanent Residence. No. 6.7.7 Bo.u.leyard st..
(Usual place of abode)
Revere ihass.
(City or town and State)
Length of stay: In place of death years months...! Slays. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
F. 4
flu
.lontn)
(S
;u.r
(Year)
4 1 H E R E II Y CERTIFY, That I attended deceased from
lO-il 19.f^.0...__ to ^ A../k J. X. , 19...fo..iC
I last saw hSJfalive on /£ , death is said to
have occurred on the date stated above, at INTERVAL
u ' BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ^ Av/~) f H 1-
(b) e.i° A AoyIc
!oe
OTHER
SIGNIFICANT
CONDITIONS
~$o
12 . .
If under 24 hours
AGE 44-Years
Months
Days
Hours Minutes
Was autopsy performed? ... „ , ^
What test confirmed diagnosis? .(.... ^...4 \...Q...C4 j.
5 Was disease or injury in any way related to occupation of deceased yj
If so, specify :Xr£>- -
(Signature)
M. D.
L4..A^m4 v
(Print or Type Name) / __ . I
(Address) Pat e j.. 19..6...;dj
ftBet.h Israel of Cambridge, Everett
Place of Burial or Cremation (City or Town)
date of burial January 19f 19....6-5
7 NAME OF . , J ,
FUNERAL DIRECTOR Am 0.1. (1 G 0X0 V
ADDRESS 1.668 Beacon. Brookline
Received and filed
JAN 191965
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED., • j
uNKNowNMarried
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife 0f.Edwar.d....W.e.i.ns..t.eiri
(Husband’s name in full)
13 Usual
Occupation .
Housewife
(Kind of work done during most of working life)
14 Industry . T T s _
or Business... At HOKie..
15 Social Security ■\n None
16 BIRTHPLACE (City)
(State or country! Mai H PIT Mpfi.9
17 NAME OF
father Harrv Gohen
18 BIRTHPLACE OF
FATHER (City)
(State or country) frJeW York CjtV
N.Y
19 MAIDEN NAME
OF mother Beatrice G B L
20 BIRTHPLACE OF
mother (City). ..Alls. ton., MASS.
(State or country)
21 Informant Edward. ...Weinstein
(Address') 6.7.7 Boulevard Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
-
(Signature of Agent of Board of Health or other)
..
(Official Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
.7 ' '
The fulfillment of the purpose of these laws calls for the observance of the-
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury
(2) Board of Health physicians will certify to such deaths only as those ioL
persons who, though disabled by recognized disease unrelated to any JgiWpff
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.
>• (
irn- t u
i u 0 Q ^ : fi
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
ed for burial permit
(Board of Health
I r its Agent.
I iTRUCTIONS
FOR
II kL CERTIFICATE
|
MT OR TYPE
I! OR CAUSES
DEATH
i not enter
d *e than one
cise for each
51;. (b) and (c)
does not mean
lode of dying,
i : heart failure.
etc. It means
Vase, or comfili- ~p-
- which caused
lions, if any,
gave rise to
cause fa),
the under-
cause last.
C tditions contrib-
! i death but not
U to the terminal
condition given
v€.
|-C\ (
I -62-9314-553
ullf? (Emnmmuuniltfy of maoHar^uoftto
12 Su.f.f.Qlk
|Q (County)
j“ Vinthrop
if i (City or T<
Pown )
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
v/int. I.i.r..Q..p.
(City or Town making this return)
| 4l> £ocic IR-S
STANDARD
CERTIFICATE OF DEATH stered Nojfl..
^ (If death occurred in a hospital or institution,
its NAME instead of street and n
PHYSICIAN — IMPORTANT
no.,,.9.1.4 Shirley. Street St. I give its NAME instead of street and number)
2 full name George ...Williams
(If deceased is a married, widowed or divorced woman, give also maiden name.)
J (Was
1 V. s.
(.if so
as deceased a
War Veteran,
specify WAR)..
..ML
..St.
(a) Residence. N0....914 Shirley. S treet
(Usual place of abode) (City or town and State)
Length of stay: In place of death.6.3years months days. In place of residence.6>iyears months days.
MEDICAL CERTIFICATE OF DEATH
death ...J.anmry.....l.8. 196.5
(Month) (Day) (Year)
4 I HERE 15 Y CERTIFY
- 19...5.Q...., to
I last saw h.iixlive on . Jan.. iE., , 196-5. death is said to
, That I attended deceased from
Ja n I F 19....6 5
8 SEX
9 COLOR
10 SINGLE
(write the jvordk
MARRIED
WIDOWED
married
male
white
DIVORCED
UNKNOWN
have occurred on the date stated above, at .. ? .05 p .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
.v...g..:...u...o..i/u..A ^
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
rs.
Was autopsy performed
What test con
hi
firmed diagnosis
5 Was disease or injury in any way related to occupation of deceased ? /.j/.
If so- specify - - : c
(Signature) , M. D.
....<&U.A..R..l£S. U..Qj^../£/V..A/S/....
(Print or Type Name) / j
(Address)
6 Winthrop Cemetery Winthrop., 1,1
Place of Burial or Cremation (City or Town)
date of burial . J..ojiu.ar.yi;«..2.1..^.1.9.6.5 ..
7 NAME OF
FUNERAL DIRECTOR
19 j
address ...1.74. Win.tflr.q.p S t.., Winthrop..
Received and filed .... IAN 21 4965 ».
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced
husband of . Josephine Flora Carr..
(Give maiden name of wife in full)
(or) WIFE of..
(Husband's name in full)
age6
0
'..Years S/ Months
21
Days
If under 24 hours
Hours Minutes
13 Usual
occupation. ...y.ar.p.e.n.t.er....& Builder.
(Kin
ind of work done during most of working life)
14 Industry
Business. self employed
15 Social Security No.. Q23-.U.-Q.Q.59
16 BIRTHPLACE (City). '.VlP-tlirOp
(State or country I Tjj P) B <3 £5 O. hi 1 PI 1. 1 H
17 NAME OF
father ".jggo Christian Williams
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Oslo
Norway
19 MAIDEN NAME
of mother Laura Chris to ohersen
.ass
20 BIRTHPLACE OF
MOTHER (City) 0.S.1.Q
(State or country) Norway
21 Informant ...Mrs., George ITT ...Williams
.9.1.4 Shirley St, Winthrop...
(Address)
A TRUE COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
w't*' me BEFQRE the burial or transit permit was issued:
n 2- ,
(Signature of Agent of Board of Health or other)
Ll&2../A...2... >
ignation) (Date of Issue of Permit) /
/
(Official Designation)
(Date of Issue of Permit)
!/.,
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(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- | .’ ' O -* —
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«f 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
c • its Agent.
II TRUCTIONS
FOR
1 l CERTIFICATE
I T OR TYPE
J OR CAUSES
C DEATH
< not enter
■ e than one
:ne for each
( . (b) and (c)
n does not mean
ode of dying,
heart failure,
:» . etc. It means
• rare, or compli-
n which caused
i.
mtions, if any,
la gave rise to
» cause (a),
Ug the under -
i> cause last.
C iditions contrib- .
I ) death but not
A to the terminal
is condition given
:-62-93lt.5S3
Qlljf (Emnmmiiuntltlj nf HlaafladjUHfttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
12
2 Suffolk
* WinthTOD ' V \W STANDARD
(City or Town) CERTIFICATE OF DEATH Registered No
.. Bay View Nursing Home c $(If death occurred in a hospital or institution,
PHYSICIAN — IMPORTANT
2 FULL NAME... £aL ,w...o ....c d.., S^ot/.v, , /(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) \ U. S. War Veteran, AO
{.if so specify WARi
p . , „ 63 Pond Street Billerica, Mass
(Usual place of abode) (City or town and State)
Length of stay: In place of death year^. months days. In place of residence. ...23,ears months days.
MEDICAL CERTIFICATE OF DEATH
3{,,^HOF....la,.Ti...u..a.r:.v AA I JL4 £
(Month)
5
(Day)
(Year)
^0
HEREBY CERTIF Yj That 1 attended deceased from
o i9...k..ht to A..V^......^.....A...Ar^. , 19 Js.A.
is said to
ve on .^..«...y..?..r..y 19<d.. death
I o y fs r-
have occurred on the date stated above, at ..T..\ “...m.
t , ,Wt\ .
I last saw h all
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(?orcvi 6 0 0/ C. ( J S I 0 V(
Due To ,4 y. tev, 0 S-C /ev c ^ / -S
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
l t4 r
X-
Was autopsy performed? _
What test confirmed diagnosis? ...£rr~....y{...V..S...^..f
5 Was disease or injury in any way related to occupation of deceased?^...
If so, specify
(Signature)
(Address)
^
ff. C.ol.<y»...S
(Print or Type Name) f ■ -
/T./j.^Date..>...>....^..^.....19.»..^....
6 Fox Hill Billerica*. Mass.
Place of Burial or Cremation (City or Town)
Jan. 26 .19. 65
DATE OF BURIAL
7 funeral director ...toward S. Reynolds ^
A DDR ESS Pj!.....Ma.S.S .
Received and filed
JAN 2 5 1965
(Registrar)
personal and statistical particulars
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
uNKNowi>ivorced
11 If married, widowed,
HUSBAND of
%(ir divorced , — .
Margaret Fewer
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
12 81 11 22
AGE. Years Months . ^ Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
Statipnary Engineer
(Kind of work done during most of working life)
14 Industry
or Business.
Qil Company
15 Social Security No..
16 BIRTHPLACE (Cit;
(Stale or country)
an-
17 NAME OF
FATHER
Patrick Scullin
18 BIRTHPLACE OF
FATHER (City)
(State or country) Ireland
19 MAIDEN NAME
of mother Mary Halloran
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Ireland
21 Informant UaiT E . Buonanamo
(Address) .63 Ppnd St. BUlerica, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the .burial or transit permit was issued:
AO' fa)
)J. C ■L -L'l/l
(Official Designa
(Signature Qf Agent of
of Health or other) /
A $ / ^ ^
(Date of Issue oil Permit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
JAN 251385 f
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
a
• n
O
t.i'-
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
reptjj-t the kind of work done during most of working life even if retired. Chil-
dren_npt gainfully employed may be returned as at school or at home. For a
wom^fr i^hose only occupation was that of home housework, write housework.
For. iftefson engaged in domestic service for wages, however, designate the
occu[fSt?oh by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
FORM R-301
for burial permit
oard of Health
|| its Agent.
ISTRUCTIONS
FOR
I :AL CERTIFICATE
HT OR TYPE
ME OR CAUSES
(F DEATH
» o not enter
ore than one
.jse for each
ji), (b) and (c)
'i does not mean
lit ode 0 / dying,
h is heart failure,
i a, etc. It means
lienii, or compli-
I which caused
iitions, »/ any, )
h gave rise to (
le cause (a), /
ng the under- I
|t cause last. )
snditions contrib-
to death but not '
to the terminal
t condition given
>-<>2-933U0h
l< Suffolk
(County)
(EnmmmiuTpaltl| nf HanaarliuaFllH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Y/inthrop
(City or Town)
Bay View Nursing Horae
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
13
Registered No.
No..
((If death occurred in a hospital or institution,
..St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Edaa L (Higgins) Robinson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
J (V\
lif-
(Was deceased a
S. War Veteran,
so specify WAR)..
(a) Residence. No. 61 P^k Drive St
(Usual place of abode)
Length of stay: In place of death years months days. In place of residence T.Qears months days.
Boston, Mass,
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 date of January 2.3 , 1965
DEATH
(Month)
(Day)
(Year)
4 1 HERE 11 Y CERTIFY, That I attended deceased from
May I , 19. 64 t0 Jan , 23 , , 19 .6.5
I last saw her live on JcL IT. # 23 , l6gj., death is said to
have occurred on the date stated above, at 11:40. ...m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute myocardial infarct
Due
(b)
Arteriosclerotic
isea
Due
(c)
Vir a 1 infection , respirator % day
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
n
min
yrs
no
Was autopsy performed?
What test confirmed diagnosis Clinical &1 aboratory
5 Was disease or injury in any way related to occupation of deceased •No
If so, sp^t^y
(Signature) [. /TYT”, M. D.
Maur ice Traunstein , f.jlf. -M . D .
73 Jan25„ 65
(Address) ......TT. •Date..
6 Oak Grove Medford, Mass,
Place of Burial or Cremation (City or Town)
Jan. 26
DATE OF BURIAL
.19.
65
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
address ...ty^throp. Mass.
JAN 2 5 1965
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
UNKNOWN^idOW
11 If married, widowed, or divorced
HUSBAND of
(Give maidei^ name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
age7A. Years.. ^ Months 3 Days
If under 24 hours
Hours Minutes
tion:... Retired (Clerk)
Occupatii
(Kind of work done during most ofiworking life)
14 Industry
Busmess: Water Proofing Co
15 Social Security No
16 birthplace (city).. 5 q in e x v x 1 1 .e ,
(State or country! MftSS.
17 NAME OF
FATHER
Frederick W Higgins
18 BIRTHPLACE OF*? » «
FATHER (City) Harwich
(State or counlr;Mcl.S S a
19 MAIDEN NAME
of mother Ola A Brown
20 BIRTHPLACE OF
Andover
MOTHER (City).
(State or country) New Hampshire
21 Informant .. Dorothy L ins
. . , , . 146 Cottage Dk-. Rd .
(Address) .£ fv'i nt hr'O'TV ; V1a'g c
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fijed with.) me^BEFOtyE the burial or transit permit was issued:
L
(Jignatuf^ of Agent of Board of -Health or oth^r)
cc-y ^
(Official Designation)^ (Da^e oi issue of Permit)
oLjM..
A TRUE COPY ATTEST:
I
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
'( ! J,
JAt/25!355 FH
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
led for burial permit
|!Board of Health
« r its Agent.
STRUCTIONS
FOR
DAL CERTIFICATE
BIT OR TYPE
j : or causes
i7 DEATH
i not enter
■ re than one
c ise for each
II), (b) and (c)
A does not mean
s[ ode of dying,
i s heart failure,
■ i, etc. It means
Mease, or compli-
ft which caused
o itions, if any,
gave rise to
ft* cause ( a ) ,
■ if the under-
• cause last.
< nditions contrib- .
if o death but not
ti to the terminal
ft condition given
jl -63-9363U8
V
Suffolk
* -b
f
Stye (Enmmiimii?altJj nf fHamaarijuartta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(County)
inthrop J? standard
(City or Town) CERTIFICATE OF DEATH
Winthrop Community Hospital
(City or Town making this return)
14
Registered No.
No..
5 (If. death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME..
PHYSICIAN — IMPORTANT
HO
.. J (Was dece
) U. S. War
V i f so specif
™£y. it Stanch! (hicuriellc) „w„ ,
War Veteran,
specify WAR}..
„ 163 Rumney Rd. e Revere, Mass.
(Usual place of abode) (City or town and State)
Length of stay: In place of death years months-.^Ldays. In place of residence IQ ears months days.
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
JyfW.UA/tY V. V. ktT
(Day)
(Month)
(Year)
3^1 HER
ILI5 Y CERTIFY, That 1 attended deceased from
T , 19 ^ to Ta.WUA A Y J f ..... pi.
I last saw h.®(falive on . t7"*A./YV.A. A V ri f* , death is said to
8 SEX
9 COLOR
10 SINGLE
(write the word)
FEMALE
WHITE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
MARRIED
-q±.
have occurred on the date stated above, at ~Jj
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
openflGLe Cafc/H «>•%* ,/
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITION'S
INTERVAL
BETWEEN
ONSET AND
DEATH
Mor.
u *
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? l*o
If so, specify n
p , £
M. D.
(Address)
it. Mm v
6 HOLT CROSS CSMmRr,...JttWm, Mass*
Place of Burial or Cremation (City or Town)
JANUARY 28, 1965
DATE OF BURIAL
19..
7 NAME OF LAWRENCE BRUNO
FUNERAL DIRECTOR "iTV1 V ..
ADDRESS
291 RE'
5 VERB, MASS
Received and filed
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced
HUSBAND of
(or) WIFE of..
(Give maiden name of wife in full)
..ROBERT. IL S.TANCHI
(Husband’s name in full)
AGE??.6i Years.
6. ...Months X Days
If under 24 hours
Hours Minutes
13 Usual
Occupation ...
HOUSEWIFE
(Kind of work done during most of working life)
or Business AT HOME
15 Social Security No..
NONE
16 BIRTHPLACE (City).. EAST BOSTON
(State or country! MASS.
17 NAME OF
FATHER
ANGELO SICURIELLO
18 BIRTHPLACE OF
FATHER (City)
(State or country)
ITALY
19 MAIDEN NAME
OF MOTHER
IDA UNKNOWN
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
ITALY
,, Informan[ ROBERT R. STAN CHI (HUSBAND)
163 RUMNEY RD. REVERE, MASS.
(Address)
A TRUE COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed wijh me BEFORE the burial or transit permit was issued:
„
(Signature of Agent of Board of Health or other)
...y
(Official Designation) (Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING XU
ORGANIZATION AND OUTFIT . .vij...,.
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the. ... _
following rules of practice: JfiPJ V '/ QoS / H
(1) Attending physicians will certify to such deaths only as those of persons ' ‘ J L
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
fi d for burial permit
h loard of Health
i its Agent.
IITRUCTIONS
FOR
111. CERTIFICATE
II P OR TYPE
S OR CAUSES
0 DEATH
d not enter
n e than one
• e for each
(i, (b) and (c)
iidots not mean
1 de. of dying,
vi heart jatlure,
n etc. It means
ii isc, or compli-
which caused
itssc
tr
ions, if any,
gave rise to
cause (a),
the under-
cause last.
Editions contrib-
death but not
•a o the terminal
1 1 ondition given
*
-62-931+553
{
[w .Suffolk
(County)
i° jVinthr.o.p.
(City or Town)
(City i
No..
®1jp (Hommamuealtii nf lEaBBarffuaettH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
.Wi.n.thx.o.p.
(City or Town making this return)
Registered No.
15
Mayflower Muraing Home 5l l».“ SFftrsI ‘••.‘I**' «
i give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
..) (Was
) U. S.
t.if so
2 FULL NAME G.harl.e.sina Yerdy C .L.eve.tt )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No... 2.53- f loasant Street st
(Usual place of abode)
Length of stay: In place of death yearsl.f .months days. In place of residence. ./.... .years months days.
as deceased a
War Veteran,
specify WAR)..
.110...
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 death,f. J.anuar.y. 2.5
(Month) (Day)
w
4 1 HEREBY CERTIF Y, That I attended deceased from
Q..&s....f.. i9.&.*:...^ to x..^.x...x,ri 19.A.C.
I last saw h.^iralive on . if... ., 19.4'., death is said to
have occurred on the date stated above, at ...X'...?L.l..t.\.m.
8 SEX
9 COLOR
f. emal e
whi te
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
C . e k..£A...\. H
I v3
Due To
(c)
17-
other
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed
What test confirmed d
^ ijL&jr
lagnosis ?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify .yj.
(Signature)
£....V?i...&...lc....£g^
(Prim for Type Name) ^
(Address) 19...&L
6 .. Win t hr op. Cemetery. linthrop., Mas
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Received and filed
ADDRESS 124. .Wintbrop. S.t.». Yinthrop
2 1 1965
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (writg the word)
married widowed
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowetfr,
HUSBAND of ft.
(or) WIFE of !Nf„
or divorced, ,r
awara Verdy
(Give maiden name of wife in full)
(Husband’s name in full)
AGE.S.d.Yf
..Months
...9....
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
house
(Kind of work done during most of working life)
14 Industrv ,
or Business O.WH 0.01110
15 Social Security No H0.]l.e.
16 BIRTHPLACE (City).
(State or country)
England
17 NAME OF
FATHER Chari es hcvett
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Engl and
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Margaret 'Baldwin
England
21 informant Mrs , Frederick B.age
(Address) .2.0. Jta.uglas. S.t Yd.n.thr.o..p.
MakSE^.,hCERTIFY 11181 8
tisfactory standard certificate of death
buTial.or transit permit was issued:
BEFORE t
-. (Slgpature of .Agent of Board of Healthior other)
Mfff, .y±hh....8;.Z.4.2£.
ai Designation) Jj (J (Date of issue of Permit)
(Official
a
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of th« 111
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 ut^
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 n | ; t pi p r
absent from home when the certificate of death is needed. JAN (j i jj.JJ liH
(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\ h
T
FORM R-301
l:d for burial permit
I Board of Health
|r its Agent.
IiTRUCTIONS
FOR
U CERTIFICATE
*
t
tlT OR TYPE
Jl. OR CAUSES
T DEATH
• not enter
nre than one
ci se for each
i|, (b) and (c)
* does not mean 'O'
|| ode o) dying,
is heart failure,
■ i, etc. It means
tease, or compli- a
J * which caused
I
mitions, if any, J „
Aii gave rise to I
■ cause la), r h
Mg the under- l >.
it cause last. J rx>
( sditions contrib-
is death but notify'
t to the terminal ~
ii condition given
IfH.e
<L » I
■63-936314.8
V
I ~
]Q (County) '
2 FULL NAME.
®lj? (EmnmmuuFaltff of HHaaHarljuHFttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
(City or Town)
/ A £ — Jr A A/ // 7 {(If death occurred in a hospital or institution,
No...'....Z...Z. Yx..YZ.Y..'..Z.. St. ) give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
/" ^ / PHYSICIAN
/>tus/fry / /«w.. *
ied, widowed or di/orced woman, give also maiden name.') ) U. S. W
V i f so spe
deceased a
War Vetera
specify WAR)
ar Veteran, yy 'y/
(a) Permanent Residence. No. Y?...6?...R. 3t.fck.A.3.A.(.A3... St.
si^/ sy 7~~Y/
(Usual place of abode)
Length of stay: In place of death..^^.. years months days. In place of residences? £(years months days
ew? (P.se
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF a a[
DEATH r J ft L a x
J&L
//ts*
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
That I
attended deceased from
UN KNOWN 6)
19 to 19.
I last saw h alive on 19 , death is said to
have occurred on the date stated above, at 6lbc...fc...
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
..p .Y..^.SU. *U ^ 4 /^-
(b dAa£.<?&..J.
j? y ^ 9 /
I)ue To
(c)
X) 1' Vo
// ?v /? %
OTHER
SIGNIFICANT
CONDITIONS
OYY — j
Was autopsy performed ?
What test confirmed diagnosis?
INTERVAL
BETWEEN
ONSET AND
DEATH
5 Was disease or injury in any way related to occupation of deceased Wd
If so, specify
(Signature) , M. D.
lk.u3RRfa.AK
(Address)
6 tr/Asr/ysfs/?
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .R.A.fa.....J.A
19.V
FUNERAL DIRECTOR ArYfa/f/Ak^ /k /KSYfR^..
A DDR ESS # /Af ,66 SS.
Received and filed
JAN 2 9 1955
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in lull)
(or) WIFE of A.A.T.R.A../A....T).. P..^/.6^k7~)6....
(Husband’s name in full)
12
AG
Years Months
Days
If under 24 hours
Hours Minutes
U Occupation jAfiAAR £/'*/.&£&
(Kind of work done during most of working life)
14 Industry ... . , «-
or Business /7 0 Y' \ ‘
15 Social Security No.. YV's/SR
16 BIRTHPLACE (City ) . At A A
AT 4-
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF .
FATHER (City). . /AfaR.
(State or country) AA ,
19 MAIDEN NAME
OF MOTHER AY/Y/YYr
20 BIRTHPLACE OF ^
MOTHER (City).. .rlAfa.. A 6
(State or country) ycy /y
(/Y*T Yi'A'SU'Yy)
21 Informant ttMl. KA. * #.**/.. ....
(Address) /..?*' YA/RRY/AfcY ^ ^
A TRUE COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me B£EORE the burial or transit permit was issued:
AURAa... ...k. . .Jbj.
(Signature of Agent of Board of Health or other)
•.x ’M.J.LY... /
(Date of Issue of Permit) w
(Official Designate
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.
t -'v :
•A '
// ' r> -> v
'Mmn? u
JAN 2 9 1905 AN
FORM R-301
ltd for burial permit
d Board of Health
jr its Agent.
I5TRUCTI0NS
FOR
ML CERTIFICATE
1) T OR TYPE
h: or causes
C DEATH
i not enter
Ore than one
c se for each
4), (b) and (c)
k does not mean
I lode of dying,
if heart failure,
It, etc. It means
Ijtare, or compli-
M which caused
li/itmr, if any, 1
■ ' gave rise to I
I cause (a), }
a. g the under- L
■ cause last. )
( editions contrib- .
•7 death but not ^
e to the terminal
is condition given
I VC •
-•63-93631*8
1
1
Suffolk .
(County)
Winthrop
(City or Town)
(£mnmnmuraltl| nf fSaflaarfjUHrtta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
in taro p
(City or Town making this return)
Registered No.
No..
hinthrop Colt unity Hospital
2 FULL NAME..
Harding
-.ichard iHilton
((If death occurred in a hospital or institution,
..St. j give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
ed, \
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Permanent Residence. No.
(Usual place of abode)
J (Was deceased a
j U. S. War Veteran, Turr\
Vif so specify WAR) AN..W..I
180 Pauline St St Vinthrop, ka s s .
Length of stay: In place of death years months..! ..Lays. In place of residence4.4. years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
deathuf. January. 2.3,..
(Month) (Day)
(Year)
A I HEREBY CERTIFY, That I attended deceased from
jr. 19. fed/"..., to .TStJ.. , 19 b.S..
I last saw h,fMVl>ve on :.4.ZL4 19.4. death is said to
have occurred on the date stated above, at INTERVAL
BETWEEN
ONSET AND
DEATH
/?mj
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
single
male
white -
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ..c.m^Kft.L...i^
Due To
(b) ...
J fr v
A'S/A/k.
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
/j^rhvrz 7>/J .IT
>/<h.
r\ ^ r\~r\
i
Was autopsy performed ?<
What test confirmed diagnosis? . 1 . /ff . I..ZZ.. . .
5 Was disease or injury in any way related to occupation of deceased J^. Q.
If so, specify
(Signat
ure) zf^A..^....
Ky./jh.. ^...l/L(/..
... M. D.
ntr. (p™it or Type Name) .
6 ..W.inthr op Geme te ry. ,. W.in.t.nr.o.p , Mas
Place of Burial or Cremation (City or Town)
date of burial January. 3Q ■» i 96 5 19.
7 funeral DiRECToiAl.f.red B^Max.s.h.
address 1..Z4: .Win.tiirop S.t.« .Win.ihr.op.,
Received and filed
JAN 2 i) 1965 ■
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in full)
AGe44 ... Years 4 Months., t. . Days
If under 24 hours
Hours Minutes
Occupation ...iraffi c. manager
(Kind of work done during most of wor- ng life)
14 Industrv
Business. . instrument and Optical Co
Security No... .Q3%.Q3.“3.5.4=2
16 BIRTHPLACE (City) Z.2.J1 t.jtirP.p. ~ '
(State or country I MaS S n.O ITUS e tt S
17 NAME OF
FATHER Philip 'Raymond Hilton
18 BIRTHPLACE OF
FATHER (City)... .Wells
(State or country) Maine
19 MAIDEN NAME
OF MOTHER
Esther Lillian Hatch
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
.Cambridge., Jtox&sdms*
Mas s achus e 1 1 s
21 Informant .. William. ...P Hilton
(Address) 480.0 S «iW... '/.2nd * S. t « Lav i e , Elas
Via
I HEREBY CERTIFY that a satisfactory standard certificate of death
,file^ witly me BEFORE the burial or transit permit was issued:
- -
(Signature of Agent of Board of Health or other)
(Official Designation) (DAte of Issue of Permit)
X
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending 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.
I ! J
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, >.
JAN 2 91955 AH
i FORM R-302
o
ii
-55.
>
Jw
fu
<
1 J
\p.
JM4M.lfaJa.e-x
(County)
Medford
(City or Town)
Oil)? (Enmmnmu?altl| nf fHaHHarljuartta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Medford
(City or Town making this return)
Registered No.
18
T o t.i r> o n o TVf/ain WnQ-rv? f al f (If death occurred in a hospital or institution,
No 00“!. 0.“:. . St. ( give its NAME instead of street and number)
Paul J. Kirby /
2 FULL NAME ... J (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) j U. S. War Veteran, rt r t t
(if so specify WAR W.W J L..
<•> No illeane Aw, s,
(Usual place of abode)
Length of stay: In place of death years months—l.lays. In place of residence^ years months days
-8
Wir.throp
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3dea?hof. January 28.
(Month) (Day)
~196l
(Year)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute .E.u.lm Edema
(^e Z.°. Hypert Heart disease
Jc)e .To Tumor of Adrenal.
other
SIGNIFICANT
CONDITIONS
hrs
yrs
yrs
Was autopsy performed? P.Q.
What test confirmed diagnosis ? op.e.r.at.i.Q.n
— ; ryr"
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) Peter H. Con tompas i s M. D.
175 Washington St.
(Address) W.in.c.he..s.t.e.r Date. Jan 2.8.19 6.81
Winthrpp Winthrqp
Place of Burial or Cremation-
Feb 1
DATE OF BURIAL
1965
(City or Town)
..19..
7 NAME OF
FUNERAL DIRECTOR
Maurice W. Kirby
ADDRESS
Received and filed
WinthroD.«_
-TEP 11365
Mass .
(Registrar of City or Town where deceased resided)
(Husband’s name in full)
AGE?™.. .Years..
Months..
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:...
Tel installer
(Kind of work done during most working life)
14 Industry
or Business:..
Tel
Co.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE (write the word)
MARRIED
widowed carried
DIVORCED
UNKNOWN
11 If married, widowed, or di^y^d
HUSBAND of
(Give maiden name of wife in full)
''Mary.E.. Breen..
15 Social Security No Q c'..d, ~* 16 *** 635 8
16 BIRTHPLACE (City) B.Q. S..t.Q..D
(State or country) S B
17 NAME OF
FATHER
Donald R. Kirby
18 BIRTHPLACE OF
FATHER (City) B.....Q..S.t.Q.n
(State or country) MaSS .
19 MAIDEN NAME
OF MOTHER
Alice Norton
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Boston
Mass .
21 Informant
(Address)
15 Dean Aye. ««inthrop
A TRUE COPY
ATTEST:
CfJ
DATE FILED
(Registrar of City or Town where death occurred)
JaB_._2.9_* 1961.:;
w
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING .....
ORGANIZATION AND OUTFIT
SERVICE NUMBER
Feb.9,1546
Gunner's Mate 3rd class
Navy
202-^6-52
o
IJi
Ij
hi
X
LO
to
.‘E'2
a
CO
FORM R-301
Id for burial permit
toard of Health
its Agent.
TRUCTIONS
FOR
LL CERTIFICATE
IT OR TYPE
OR CAUSES
DEATH
not enter
|re than one
se for each
(b) and (c)
does not mean
ode ol dying,
heart failure,
etc. It means
I’.ase, or complt-
which caused
lions, if any,
gave rise to
cause (a),
g the under-
cause last.
tditions contrib-
> death but not
to the terminal
condition given
iM.e,
U<L» (
+63-93631+8
QIljp (Hmnmmtuipaltlj nf fSa&aarljuflpttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Minfchrp.p.
(City or Town making this return)
lw S..uf.£o..lk
|Q (County)
jP IJinthrop.
(City or Town)
\i No Winthrop. Cornmunity, Hospital s, J(givdeeush name' inMeldboTs^r^d^umt?)
PHYSICIAN — IMPORTANT
STANDARD
CERTIFICATE OF DEATH
Registered No.
11)
2 FULL NAME .G.h.ai?.l.S,.S..,..i.i... B..U.S..S..S.11
(If deceased is a married, widowed or divorced woman, give also maiden name.)
j (Was
) U. S.
V i f so
as deceased a
War Veteran,
specify WAR)..
WW2
(a) Permanent Residence. No 6.3 HarbO £... V ieW Ave. St WinthrOp.., MSS.
(Usual place of abode) (City or town and State)
7 IP!
Length of stay: In place of death years months .(..days. In place of residence Wlyears months days.
MEDICAL CERTIFICATE OF DEATH
3 DEATH0™A~.n.^
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
i9..\.S.., to...A..r?r...s?\...Tt.^.' , 19‘bS
I last saw hV.Ufilive on .:\v..v>...:..\. ^ 19..W.^ death is said
have occurred on the date stated above, at Oi: ...Th.S.$\.m.
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
OY \v»V>C^ +4-
Due To
(c)
signufican’t’ . -..''T'
/-rwi-tn'T/ivc '
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
rvW
\r\rtYf "|V,
Was autopsy performed?
What test confirmed diagnosis? .
5 Was disease or injury in any way related to occupation of deceased?
If so, specify Ss5lDl_
(Signature) IjSX
' * £>. ?.
(Address)
a. , M. D.
n >,>\N\lpsrknb°i3ryp* Name) ^ ,
...SwXj...V.>ASt^Li^3^^^.Date...\.....~..T>^( 19...\*2s.
6 Q.ak. ...Grove Ke.w....Be.dfor.d
Place of Burial or Cremation (City or Town)
DATE OF BURIAL 19.65.
funeral director ..Howard S ...Reynolds
ADDRESS
Winthrop Mass
Received and filed
JAN 2 9 1965
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED CT nprl p
UNKNOWN Ol+lgXe
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE
55 . Years 7
ears../ Months J Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
Teacher
(Kind of work done during most of working life)
14 Industry
or Business
Electrical
5 Social Security No.. .[removed].
i6 iurihit.ack (CityiNew Bedford
(State or country) MclSS
17 NAME OF
father Charles A Russell
18 BIRTHPLACE OF _
FATHER (City) NSW. B.e.d.f Ord
(State or country) T.fafic;,
19 MAIDEN NAME
of mother Leah Billington
20 BIRTHPLACE OF _ , - ,
mother (City) New Bedford
(State or country) MaSS#
21 Informant Blizabe th Whynot
(Address) Ney Bedford, Mass,
COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
filed ^yith sjrtc BEFORE the burial or transit permit was issued:
e fif Agent of Board of Health or other)
o y^....±.L./J±±. a
(Date fa Issue of Permit) fa Lf'
(Official Designation)
<
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
2, 15ikA*.
SlLft.4-..i.ua5
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.
r TO: -.
i'..'
i
2 91355?*
(Snmmimuimtlj hi HHaafiarljufirttH
'ORM R-301
d for burial permit
ard of Health
Agent.
HTRUCTIONS
FOR
ill L CERTIFICATE
II T OR TYPE
S OR CAUSES
0 DEATH
d not enter
Ti* e than one
:a e for each
(i, (b) and (c)
tii does not mean
jllde of dying,
heart failure,
■» etc. It means
it ise, or compli- .
m which caused
1
ions, if any,
gave rise to |
cause (a), ,
1 the under- I
in cause last. ]
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
lw....S.U.ff..Q.l.k
lQ (County)
J° ..Winttirop.
I(j (City or Town)
J 7A Clnv.n-ov,+ Q 4- to q q +■ „ Hu aeatn occurrea in a nospital or institution,
\ C-, No O.Q-J^.^.SXLX O.XJ/.6.S..X St.) give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(City or Town making this return)
STANDARD 0|f.
CERTIFICATE OF DEATH Registered No iftii
((If death occurred in a hospital or institution.
(Was deceas
) U. S. War V
V if so specify
2 full name .Alfred Carlton
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 5-Q S£L.X!{9J.QXli .t>.XXl..0..0..X. St
(Usual place of abode)
Length of stay: In place of deatl4:.s3-years months days. In place of residencA.8. .years months days.
deceased a
Veteran,
WAR)..
NO.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF 'T~A .■> /
DEATH . / /f .1
xf,
L9ASZ.
8 SEX
9 COLOR
(Morfth)
dM)
(Year)
4 I HEREBY CERTIFY
, That I
attended deceased from
male
white
19 to 19
I last saw h alive on I , 19....,..., death is said to
have occurred on the date stated above, at ... 4.m-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(br...I°...b...^..^Mr.v:5/ (LgMS
p...E (£• S U &t (j cjun.. Ac.
ditions contrib-
death but not '
to the terminal
condition given
£,e W±^.1M±E
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
(Give maiden name
of wife in full)
(or) WIFE of
(Husband’s name in full)
If under 24 hours
AGE. i/. D. Years / Months. Days
Hours Minutes
w.e.
U; i
Was autopsy performed? A/..0...
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased Wo
If so, specify
M. D.
(Signature)
(Print or Type Name) j j
(Address) .Date..../.y.£n.$.y/.19..
6 ...Wlnthr.Q.p .C.e.m.e..t..e.r.y.., W.in.t.h.r..Q.p....... Ma x
Place of Burial or Cremation (City or Town)
>5. _ i.
DATE OF BURIAL ....E.ebPUa
address .1.14 W.in.tffr.Q.p .S.t... .Wlnt.ar..Q.p..,
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)-,
married widowed
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
13 Occupation r. pt i r e d.... Cap t .
(Kind of work done during most of working life)
14 Industry
Business Harrow Gage Ferries
15 Social Security No ilO.I.'..6.
16 BIRTHPLACE (City) t^.O aC.e.S. tOT
(State or country)
■la g 5 achus e Its'
17 NAME OF
FATHER
Pfit.pr Ai3gimt.ua fiarl ton
18 BIRTHPLACE OF ,
FATHER (City) h.tO..Cj£hQl.JIL
(State or country) Sweden
19 MAIDEN NAME
OF MOTHER
limy Barrett, Caroner
20 BIRTHPLACE OF n ..
MOTHER (City) fit Q.TJL.C.SS. t QT„
(State or country)
Bassaohusetts
21 Informant ..Mis.s....lucy.....B.arr.att Carlton
(Address) .30. Sargent S..tr.e..e..t.,..W.inth.r.Q.p..
IEREBY CERTIFY that a satisfactory standard certificate of death
’ filejj! -"ith me BEFORE the burial or transit permit was issued:
Received and filed
•(-62-93ES53
„ W&3 C', . - - -
j (Signature of- Agent of Board of Health or other)
:3t&Jc?.. . . /.*. . . /...ft.. . . ..^
(Registrar) |l (Official Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance 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.
CO
ORM R-301
d for burial permit
ioard of Health
its Agent.
TRUCTIONS
FOR
L CERTIFICATE
f OR TYPE
. OR CAUSES
DEATH
I not enter
I: than one
le for each
I (b) and (c)
I loes not mean
I it o f dying,
I heart failure,
i etc. It meanj
Lie, or compli- -p.
I which caused
\ions, if any,
I gave rise to
ii cause (a),
ii the under-
I cause last.
tlitions contrib- .
I death but not
I o the terminal
I'ondition given
I
' 3-93631+8
\c$//o $1jp (Cmnmnmuealtlj of fHaflaadjuaftta
[i Suffolk
^ ■>
(County)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
STANDARD 0 f
CERTIFICATE OF DEATH Registered No Xll
((If death occurred in a hospital or institution,
Winthrop
(City or Town)
n Cltff House Nursing Horae St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME. ...William Greenberg
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
j U. S. War Veteran, /!/
lif so specify WAR) f r:...
(a) Permanent Residence. No. 311. Washington Avenue st Chelsea. ..
(Usual place of abode)
Length of stay: In place of death years.. 2 -months days. In place of residence 1... years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
DEATH ^CX'CVw 0....\f..Ld *<>-Q aU
(Month) ' (Day)' (Year)
4 I HEREBY CERT IF Y. , That I attended deceased from
i9..fo..^..^, to 19...V.S..
I last saw h.i.^live on -A & V\ seK , 19..\o.^ death is said to
have occurred on the date stated above, at I INTERVAL
BETWEEN
ONSET AND
DEATH
‘>OVTV V")
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ..)
f cY vCxi \ N>.^auCV.. C;..*.n.
<b“e .. 1 .&< V.'t.c.V\eaA. dv^.^.fe
Due To
(c)
•y'S Ac* * A
OTHER
SIGNIFICANT
CONDITIONS
Vyvv ^..cA
Was autopsy performed? SSVP
What test confirmed diagnosis? A.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify —
(Signature) . . . . . TU. . . - , ^
Name)
lSS>ate.\..“.SI.?
M. D.
..19...*
6 Beth Israel Cemetery Everett
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
January 31 19.6 .5
1 FUNERAL DIRECTOR Tori* Funeral Service.
ADDRESS
Received and filed
FEB 15 1965
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
divorced Mfl-rr*! pH
UNKNOWN milieu
11 If married, widowed, .or divorcoi
husband of ...Ev.elyn .L* Bl oom
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
AGE 53
Years Months .
Days
If under 24 hours
Hours Minutes
Occupation .. Salesman
(Kind of work done during most of working life)
14 Industry
or Business.
General Merchandise
15 Social Security No... [removed]
Somerville, ^
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
father Abraham Greenberg
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Esther Feldman
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Russia
21 Informant Evelyn Greenberg j
311 Washington Avenue, Chels<
(Address)
151 Washington Avenue. Chel:>eai HEREBY CERTIFY that a satisfactory standard certificate of death
* * ur n c fi lari urifVi ma P 17 C D D IT (Via Kuriel nr froncif narm 1 1 woe ICCII^H*
was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
(Official
J o. / <j Ls"
cial Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the h j «-> . ~ n
following rules of practice: - C 1
(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.
1
ORM R-301
d for burial permit
loard of Health
its Agent.
rRUCTIONS
FOR
. CERTIFICATE
I" OR TYPE
I OR CAUSES
: DEATH
i not enter
t : than one
le for each
l (b) and (c)
t toes not mean ,
I ie of dying, i
I heart failure,
j etc. It means ^
. se, or compli-
r which caused V
i.
V
Hons, if any,
agave rise to
ti cause (a),
ii the under-
g cause last.
Options contrib-
I death but not
I > the terminal
! ondition given
■
H
>
*
S5
1.62-934-553
QI1|? (Cfltmmmmniltfj at fHaflaarijuHPttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Win.tnr.Q.p.
(City or Town making this return)
Suffolk
(County)
(Un
)° Winthrop
(City or Town)
o C. Hirovina ((If. death occurred in a hospital or institution,
' Cl, No C-.O _I LUinjQ.e. r jfLY.e.XlU.w. St. | give its NAME instead of street and number)
• PHYSICIAN — IMPORTANT
STANDARD
CERTIFICATE OF DEATH
Registered No.
22
j (Was
3 U. S.
\.if so
2 full name S ai* ah ...Martha S^o .(Re#d 0
(If deceased is a married, widowed or divorced woman, give alsoanaiden name.)
(a) Residence. No 26 ElUmmeX. AVSIUie St
(Usual place of abode)
Length of stay: In place of deat)4-Q...years months days. In place of residenc4-.Q..years months days.
as deceased a
War Veteran,
specify WAR)..
NO.,..
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF t
DFATH V
...10.
1..9.6.5
8 SEX
9 COLOR
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
That I
attended deceased from
female
white
19 to 19
I last saw h alive on 19 death is said to
have occurred on the date stated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .
(b) e^°
Due To
(c)
\jQi\AA X9 p 3 m rs( ^ M..{ tM*
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specif,
<s' ^MkeZaT. : M "
i
(Address) l
6 ,...W±nihr.Q.p .C..e.m.e..t.e.r.^.,..M.n.th,r..Qp
Place of Burial or Cremation (City or Town)
:narv.
DATE OF BURIAL i
7 NAME OF
FUNERAL DIRECTO
Received and filed
a ddr ess ..1..7..4 V/.inl4.r..Q.p .S.t... .iyi.xithr..Q.p..,
1965
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
married idowed
WIDOWED iUU,VCU
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of ...
(Give maiden name of wife in full)
(00 wife of Williajii....He;riry. S.op.er.
(Husband’s name in full)
AG&6....V ears (3. Months 1 ..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation ... h.Q.us.e.wife
(Kind of work done during most of working life)
14 Industry _____ —
or Business QWX1 ...h.QIJl.e
15 Social Security No XI Q US
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
J ames RelA
New Foundland
19 MAIDEN NAME
OF MOTHER
Wary Hands ford
20 BIRTHPLACE OF
MOTHER (City)
(State or country) NeW FOUXldland
21 Informant ... Arthur..... J..* S..o..p.er
(Address) 2.6 Pl.uram.er AY.e..*.lin.t.hr..Q.p.
--I HEREBY CERTIFY that a satisfactory standard certificate of death
i.!ch£a£3fiied with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or either)
2/ (S. ^ J
(Official Designation) (Date of issue of Permit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY ^SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
£R _ p * m
r ' " ■ %
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.
^ORM R-301
II for burial permit
I oard of Health
| its Agent.
ITRUCTIONS
FOR
IL CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
; than one
le for each
i (b) and (c)
kioes not mean
ti ie o) dying,
a heart lailure,
n etc. It means
lire, or compli-
s which caused
K ions, i I any,
c gave rise to
I cause (a),
i the under-
■I cause last.
’< litions contrib- -
i death but not
do the terminal
t ondition given
w\.c..
i vO <L • I
I
v/7
z
0
£
1
\ h
ri
vi
*
o
oc
2-932302
3 ^.v..EEc. LJ^
ifi (County)
c . r ,o.
(C* ifv nr Tnwnu
(City or Town)'
No IQ O
©If? (SommnnuiBaltff of HaBaarI|UH?ItB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
A\f.£.
(City or Town making this return)
23
Registered No.
f (If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME
, ' ! \ At ~7 — ' PHYSICIAN — IMPORT
/Me eo C 4 J / (Was deceased a
(If deceased /s a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran,
c V i I so specify WAR)..
(a) Residence. No...(f...^?.. .£?... Q.U...L MCM /^Br.
(Usual place of abode) * ‘
r
Length of stay: In place of death.(>f.... years months days. In place of residence. TO years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE
DEAT
HOF.....!^^s3.a Cv\ M
(Month) * (Day) (Year)
(Day)
4 I HEREBY CERTIFY, That I attended deceased from
..I'lZ.'fc? >.V.., 19 V.rvr, to.....^.<X.VY !2> V \9.\tf~3..
I last saw IrA-falive on M ^ ys rt>.\ 19.. ..Wreath is said to
have occurred on the date stated above, at /./.;.r.^r....i^-....m. I INTERVAL
BETWEEN
ONSET AND
DEATH
■z Ws
8 SEX
9 COLOR
10 SINGLE (write the word)
/=■
iU
MARRIEC * A
UNKNOWN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
v Vs
Due To
(b)
Due To
(c)
SIGNIFICANT QLYV«-0 CU^ VA ? C
CONDITIONS 1 '
Jt
T
tA
Was autopsy performed ? kY»
What test confirmed diagnosis ? .*!!?.
njury in any way related to occupation of deceased?
5 Was disease or
If so, specify ...
(Signature)
(Address)
, M. D.
nt or <£yp e Name)
Date...^...-...V.
..19...
/eee.&rlT
Place of Burial or Cremation « (City or Town)
Sr
DATE OF BURIA-
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
ML
M: £.
Received and filed 19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced
HUSBAND of
(or)
sr— (Give maiden lume oLartfe in -full )_
WIFE of til. ., ,(r/7SX
(Husband’s name in full)
12 .
AGEy|g|^Years...gSCUJMonths<^7^ Days
13 cSation: //s/j CL LL) J
If under 24 hours
Hours Minutes
(Kind of work done during most working life)
14 Industry
or Business:.
15 Social Security No
16 BIRTHPLACE (City).../? / /..SCa~
(State or country) #1 /)/
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
^ H e/
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
fc
19 MAIDEN NAMeRoS^b iN /A f"; \~z.Si VrtYY) 0 N <L
OF MOTHER A? O y A
4?
LO * wf 7ck
(Address) . (
o CUc t /ricV ^
, I HEREBY CERTIFY that a satisfactory standard certificate' of
21 Informant,
( Address)
Official Designation^
(Official
satisfactory
: burial o:
of Board of Health or other)
A-t...L..ciA.£.
death
wat filed with, me BEFORE the burialjor transit permit was issued:
£ra^C‘ (L y&u
(Date of Issue of Permit)
JW
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER ........
' /// -
HR
RULES OF PRACTICE
FEB
mnc; P
, IDUO '
M
n
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.
£ *
4
MR-301A
RUCTIONS
FOR
L CERTIFICATE
giving
OF DEATH
not enter
than one
| for each
(b) and (c)
does not mean
e ol dying,
heart failure,
\etc. It means ^
p. or eompli- *
which caused
MM, if any,
gave rise to
B cause (a),
I! the under-
L cause last.
t ions contrib--
y death but not
ih the terminal
\ edition given
5 Chapter 137,
1 1954, requires
c ns to print or
lie cause or
s if death on
Irtificates.
r
I
_Suff o.lk.
(County)
:■
(Ulf? (Emnmrmitraltlj of iEaafiarljufirtts
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
ursing Home
. '
To be filed for burial pefthlt
with Board of Health
or its Agent.
Registered No.
Wlnt.hr op
(City or Town)
Orf ^ 'all* ' 6 ” f (If death occurred in a hospital or institution,
No J / Lrrovcrs AV e . , St . I give its NAME instead of street and number)
( PHYSICIAN — IMPORTANT
(If decea*JPi?PE^rt!?ieid(Wed oPll3vJr<V flworaan, give also maiden name.)
' (Was deceased a
) U. S. War Veteran, KI/-\
if so specify WAR)
(a) Residence. No 64 Prospect Ave
(Usual place of abode)
St.
Length of stay: In place of death./C years..
months
(If nonresident, give city or town and State)
days. In place of residence ^)0 years months days.
MEDICAL CERTIFICATE OF DEATH
DATE OF A k l
DEATH /V
(Month)
31
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
— k * , 19^(5. .^_to -Jt q jet ^ B t , i9.tr
I last saw h f^falive on s J . i - jf , 19 , death is said to
have occurred on the date stated above, at //t‘/0 r
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
/)c^<g 6? ore Wiry $00 fits l oh
fji/perfch Side ''fiy'bpXiG -
5 cldrc'f^c He^vf £> > sgetse
Due To
(b) - /
Due To
(c)
CONDITIONS/** / Aeafir Sist .A • 7
c ,y\A
Was autopsy performed?
What test confirmed diagnosis ? -^3-/ * -Vt *
INTERVAL
BETWEEN
ONSET AND
DEATH
Ahr-
,51
rs
8 jrs
V£krs_
5 Was disease or injury in any way related to occupation of deceased ? Afe
If so. specif
(Signed)-
(Address) u,nrnftce,MA$S Date / J 3i
6 Garden Cemetery
Place of Burial or Cremation
M. D.
DATE OF BURIAL
February 3 ,
Che 1 sea. Mass.
(City or Town)
19..£f
7 NAME OF ■ , | T
FUNERAL DIRECTOR AT tflUT d
ADDRESS
Q1 Malay
WinthrQp,.._Mas_s
Received and filed
FIB 2 4965
(Registrar)
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED . . . , ..
or di vorcedW i do we d
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of John J Silva
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE
.8.6.
L Years — -. Months — Days
If under 24 hours
Hours — Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
’Mr"' Business: _..QWXL IlQUlfi..
15 Social Security No...
16 BIRTHPLACE (City) BO-S-tOIL.
(State or country) MBS S
17 NAME OF
FATHER
Robert Beard
18 BIRTHPLACE OF
FATHER (City). -BOStOn,
(State or country)
Hass
19 MAIDEN NAME
OF MOTHER
Mary Willard
20 BIRTHPLACE OF
MOTHER (City) _ BOStQn.-
(State or country)
Mas r
Informant Robert Silya,
64 Prospect Ave.
(Address)
W inf hr op
I HEREBY CERTIFY that a satisfactory standard certificate of death
wasifiled with me BEFORE ihe burial or transit permit was issued:
fluuL 6.
, (Signature of AHjemt of Bq»rd of Health or other)
. ^
(Official Designation/ (Date of Issue of Permit) , /
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one, where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word "war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury orotherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerK
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. by a satisfactory certificate of the attending physician, if any, as required by
law, or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by. section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar. may require. — Chap. 114, Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38, Sec. 6 , as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.
. . . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of the^se laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only aS those of
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance; or whose physician is absent
from home when the certificate Df 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, pr^leoxrical ageiits, and deaths following abortion, but
also deaths from disease resulting- from injury or infection related to occupation,
the sudden deaths of persons pot .disabled by recognized disease, and those of
persons found dead. '-O ' ‘
Statement of Cause of- Death. — Physicians: see explanatory instructions
on face side of standard ceftipqate-of'deLfh^ CT f u
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-302
u So
°-s -
>.2
II*
<« X
eo.
C— 10
if5
•a o «
/
IS Middlesex
(County)
utyp <£nmmmuuFaltf| nf fHaBBarijuBFtta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Melrose
(City or Town making this return)
F Melrose
/£} (City or Town)
' * No....aplborr)e Mur sing.. Home
COPY OF
CERTIFICATE OF DEATH
Registered No.
25
((If death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
2 full name J oseohin© M, Danahy
(If deceased is a married, widowed or dTv<
Vorced woman, give also maiden name.)
/o
1“
(Was deceased a
U. S. War Veteran,
so specify WAR)..
(a) Permanent Residence. No 53....Tho.rntan...Rark st WinfchrQp.»...ItoiWU
(Usual place of abode) (City or town and State)
Length of stay: In place of death..3»....years«» months21 days. In place of residenc^O years** months days.
u ° X.
sjs;
c •-
o >
IsE
o?
Bgo
u o ^
-c-5
E 0>o
T3 «j C
CJ «-* trt
u.t: o
3E*G
: 3*5
!j=*£
^ c
oo
*0
t/>
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January. 15, 1965
(Month) (Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Dec* 2u 19...6U , to . January 15* > 65
I last saw er .alive on .. January 13.^ , 190-5. death is said to
have occurred on the date stated above, at6 *ll5E m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ..Q.ere.br.al....Thr.orabQaia 2
Due To
(b)
Cerebral Arteriosclerosis 5 yrs
Due To
(c)
SIGNIFICANT ..Y^Diliby
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
mos
2 yrs
Was autopsy performed? No.
What test confirmed diagnosis? Lab tests*
cal
5 Was disease or injury in any way related to occupation ol defeased ?NP
If so, specify
(Signature) T.hom9..s....M.«....H.ear.ne m. d.
(Address) Jelr.oa.a,....Mass.* Dat«J.an*l6, 196.5..
6 ...nujLy... Cross ‘.Ia.l.d.en>....Ma.s.s..«...
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
January 18. » 1965..
7 funeral director J..Qa.fip.h....G.ur.nanfi..
ADDRESS 516 Broadway, .Evi
Received and filed
»...Masa...
(Registrar of City or Town where deceased resided)
8 SEX
9 COLOR
Female
White
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE
MARRIED
WIDOWED
(write the word)
divorced Single
UNKNOWN &
11 If married, widowed, or divorced
HUSBAND of m ...
(Give maiden name of wife in full)
(or) WIFE of rs
(Husband’s name in full)
12
AG 69_ Years... 3 Monthl6 Days
If under 24 hours
Hours Minutes
Occupation : Home. . . maker
(Kind of work done during most of working life)
or Business:. .. Qw.n.Hojas
IS Social Security No. .
Q31-Q3.-3.33K
16 BIRTHPLACE (City).
(State or country)
Boston
Mass.
17 NAME OF
FATHER
Jeremiah Danahy
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Unable , t o. obtain
Ireland
19 MAIDEN NAME
OF MOTHER
Margaret A. Howard
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Unable , to .obtain
Ireland
21 Informant John P. . Dana hy (brother)
tAddreso53 ...T.ho.rntQn...Park,>iint.hr.o.p..,.. Mass ,
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED . January... l8,....1965 19...^..^:
7,
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ltd
to
Era
co
UJ
ORM R-301
for burial permit
>ard of Health
ts Agent.
RUCTIONS
FOB
. CERTIFICATE
OR TYPE
OR CAUSES
DEATH
I lot enter
l than one
P: for each
(b) and (e)
oes not mean
fe o / dying,
heart fatlure,
1 etc. It means
se. or compli • .
which caused
ts. il any,
lave rise to
\cause (a),
the under-
cause last.
mitions contrib- ^
I 'death but not
the terminal
mdition given
938000
,J)Uf - OF TOWN
Suffolk
(County)
Boston
(City or Town)
1 \o
(Enmmmtuiraltlf nf H&nBBact}UB?ttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
20
(City or Town making this return)
0076.'?
STANDARD
■a**' CERTIFICATE OF DEATH Registered No
XJfe |(givtf?ts NAME^nMeadho*^treerand*number)
PHYSICIAN — IMPORTANT
Frank S . Taylor
2 FULL NAME .77..7.7T*. T* ~ j (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran. SAW
(.if so specify WAR)
(a) Permanent Residence. No 5.5 Somerset _ Ave . XX ...Win.thrpp , . JfeSS.
(City or town and State)
12
Length of stay: In place of death years months.-r~.days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 deathof. January 20 1965
(Month) (Day) yf^
(Year)
1 I HEREBY C LliT IKY, That Intended deceased.. Lc<
Jan, 8 19 6.1, to Jan. 20 ,, 65
Dra20S2?IX2GQSG(IXXXXX^ ., death is said to
have occurred on the date stated above, at 11.S.5.5A ,*m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a, ..Pul^nary and cerebral embolism.
Due
(b)
Hypertensive and arteriosclerotic
j„Hypc
•heart
disoaoc-,6-?i-th--old-posterioy
Due to myocardial infarction and auy
(c) fibrillation,
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
iculai1
^Ycars-
Was autopsy performed? .Yes
What test confirmed diagnosis? Autopsy
S Was disease or injury in any wax related to occupation of deceased?
If so, speci fy . a
(Signature)
M. D.
ulian...EIpfator,....M«Il.«
(Print or/fype Name) z
(Address) yAH.,.B.Q.S.t.Qn.*mas, Date.. Jan.‘ 2019 6>
6 Winthrop Can,, Winthrop » Mass,
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
January 22 ,0 6$
7 FUNERAL DIRECTOR
address Winthrop St., Winthrop, Mass
Received and filed
JSQfSK
..19..
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED Ma nr*? pH
divorced namea.
UNKNOWN
11 If married, widowed, «r divorced, — . , ,
husband of .Elizabeth Southard
(or) WIFE of
(Give maiden name of wife in full)
(Husband's name in full)
cVqige78
Years 1^ Months H Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
Electrician
(Kind of work done during most of working life)
14 Industry
or Business:
Electrical
15 Social Security No
16 BIRTHPLACE (City).
(State or country I
■Fitchburg-
' Mass.
17 NAME OF
FATHER
William E. Taylor
18 BIRTHPLACE OF
FATHER (City) -
(State or country) MaSS.
Pepperell
19 MAIDEN NAME
of mother Sarah Kemp
20 BIRTHPLACE OF
MOTHER (City)....
(Slate or country)
Groton
Mass.
21 Informant A. Hospital ReCOrdS, 150 S.
(Address) Huntington Ave., Boston, Mass.
I HEREBY CER/oiF^— Lhnt_ a satisfactory standard cert'/bue of death
lis fiJe<L^i(3rvVtK^EFOKEjtlie BUrial or transit permvVtfas issued:
y
'LA
H
l ic; nature of Agent oTBoord of Heaith or* other)
t~37=
(Official Designation) L (Date of Issue of Permit)
DRM R-301
for burial permit
>ard of Health
ta Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
tot enter
than one
for each
(b) and (e)
oes not mean
e o) dying,
heart latlure,
I etc. It meant
Ire. or compli ■
■chick caused
\<mt, 1 1 any, 1
Ifotie rite to f
I couje (<), f
• the under ■ l
\ cause last. I
13
titions contrib-
N death but not
p the terminal
Rendition [iven
12 1965
1-1-936348
=OUT - OF - TOWN ^
JaT
QJljr (£mnmmiuiralti| af fSaeHarljuflpllH
(County)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
27
(City or Town making this return)
o P /\ Y/? £4 /P V >,V' ,yrf J3 STANDARD
(Otyor Town) CERTIFICATE OF DEATH
Registered No (C>t
No
OEH'/£#
PHYSICIAN — IMPORTANT
2 FULL NAME..
(If
%£8srrc/9 MAL "YS V / (Was deceased
f deceased is a married, widowed or divorced womatf, give also maiden name.) j U. S. War Veti
V i f SO specify W
Veteran,
specify WAR)..
>. Si:... s.
Length of stay: In place of death years months^^days. In place of residence A*.Q> ears months days.
(a) Permanent Residence. No.
(Usual place of abode)
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
J 3±t /ties
(Month) / (Day) (Year)
4 I HEREBY CERTIFY, That 1 attended deceased from
i9...?.l to JA'/YAA y. ..3.A
I last saw hCr.rTalive on .JA'V.</.e9.&y. So, /<Mr death is said to
have occurred on the date stated above, at ... SU.PJPr
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) C#k//A'AM/?7 ££*//.. T.AA. oftca
INTERVAL
BETWEEN
ONSET AND
OEATH
Vs
(b)
Due To
(c)
F/s.TMLA7 As ///Z £/l*££&
OTHER
SIGNIFICANT
CONDITIONS
G A/ty/sA/QjL
d£T£/l /o 5 c2
Was autopsy performed? .. Me
What test confirmed diagnosis? ...C///y/.C/)A
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
M. D.
(Print or Type Name)
(Address) G 4./..
6 ....Tif.ere.th Israel of... Winthrop , Ever
Place of Burial or Cremation j yty 6$
DATE OF BURIAL
7 FUNERAL DIRECTOR Torf... .Funeral Service
ADDRESS
Received and filed
151 Washington Avenue, Chels
elpIIisssIZ
- O.
A TRUE COPY ATTEST:
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
(write the word)
10 SINGLE
MARRIED
WIDOWED
DIVORCED », . ,
unknown blamed.
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
of Hym.an...Malinsky
(Husband’s name in full)
(or) WIFE
12
I 13 Usual
A/#/V77y5 Occupation
64 ears Months Days
Housewife
If under 24 hours
Hours Minutes
(Kind of work done during most of working life)
H industry At Home
or Business..
15 Social Security No..
none
16 BIRTHPLACE (City).
(Stale or country )
Russia
17 NAME OF
FATHER
Samuel Cooper
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Lena (CBL)
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Russia
21 Informant
Hyman Mai in sky
35 Nevada Street, Winthrop
BY CERTIFY that
1 with me BEFORE
'satis/actory standard certificate . of dea th
fie bufial or transit permit was issued:
<v._ —
l^ignajure of Agentif Boari^f f^galt^R other)
(Pflici.il Designation) / (Date o/iisue of Permit)
IfjJ/
A TRUE COPY ATTEST:
(s ,Qf
FORM R-301
d for burial permit
iloard of Health
i its Agent.
I TRUCTIONS
FOR
II CERTIFICATE
ir OR TYPE
OR CAUSES
I DEATH
i not enter
a: than one
le for each
'H (b) and (c)
Uloes not mean
| it oj dying,
1 heart latlure.
r. etc. It means
\i ue, or comfli-
u which caused
Ui ons, il any,
ic gave rise to
>t cause (a),
li; the under-
si cause last.
Z clilions contrib- .
i death but not
d ; the terminal
te ondition given
< 1
I L
9 3 -9363b8
(Emnmrnmipaltlf of fHanaadjuflEttfl
< Suffolk
1C (County)
0 Winthrop
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No : 28.
v V.TNTHROP COMMUNITY HOSPITAL ((If death occurred in a hospital or institution,
No St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name Soh.1 Sparer
(If deceased is a married, widowed or divorced woman, give also maiden name.)
) (Was deceased a r.rt.T
j U. S. War Veteran, "
V if so specify WAR)
(a) Permanent Residence. No. ... 29 ..Tewksbury St. a st fffoforoP» Mass
(Usual place of abode) (City or town and State)
Length of stay: In place of death years months days. In place of residence 1 Qears months. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
February 1
(Month) (Day)
1965
(Year)
4 I HERE I! Y CERTIFY, That 1 attended deceased from
to IZ.Q. h) Lt. , 19.AST...
I last saw h^v\^l>ve on . 3...L.4 19.&X death is said to
have occurred on the date stated above, at ... 7«3.0../L..m.
8 SEX
9 COLOR
Male
White
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) . y /.€.t >’«! 5 e. I.eyo /i' g. Me cly^z.
Due^To 1) s ease.
(b)
Due To
(c)
SIGNIFICANT jA ...HA A A*A.9^...
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
S
Was autopsy performed?
What test confirmed diagnosis? Ct 1 V i LCl ...l
5 Was disease or injury in any way related to occupation of deceased
If so, specify
^ nl~ IX
(Signature) _
U.IK&&MA.AJ..
(Print or Type Name) , / /
(Address) {JJ.J..A/.AH.(?D.f; ..foi.fogS-Date. 19.A1
6 Golden Crown Wobur n
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .F 6.6.0: a T J 2 y
..19...VV..
7 NAME OF
FUNERAL DIRECTOR
Stanetsky '•iemorj.e l Cha oe l
Een.i '
i e n j a m i n b i.r .n.b a .c
i? L onapi
Birnba.ch
address 10 Washington S t, ,Dorcheste
feb f 1965
Received and filed
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED ^ .
widowed Single
DIVORCED
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
k ?..Y
■ Years Months Days
If under 24 hours
Hours Minutes
Usual
Occupation.. Wildlife & Fish. Dept „
(Kind of work done during most of working life)
14 Industry TT c n x
or Business U •.£>.. #.\J Q V V •..
15 Social Security No..
[removed]
16 BIRTHPLACE (City).
(State or country!
Somerville , Mas s c
17 fathfpF Nathan Sparer
FATHER x
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Austria
19 MAIDEN NAME _ , , _
of mother Gertrude Pearlmutter
20 BIRTHPLACE OF
mother (City) Aus tria
(State or country)
21 Informant
Nathan Sparer
(Address) 29 Tewksbury S t .. , Win thro p
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
A&h -
(Signature of Agent of Board of Health or other)
*
(Official Designation)
(Date of Issue of Permit)
A TRUE rOPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE No.Y^nib®^ 6, 19k2
DATE OF DISCHARGE December...^... 19^.5.
RANK, RATING L*L T.9..T..'
ORGANIZATION AND OUTFIT U.AS .Army.
SERVICE NUMBER 3.1226600
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.
TO!'/
FES -51335 m
FORM R-301
led for burial permit
Board of Health
>r its Agent.
ISTRUCTIONS
FOR
l:AL CERTIFICATE
1 IT OR TYPE
Pi OR CAUSES
F DEATH
> not enter
re than one
ise for each
i), (b) and (c)
does not mean
ode o) dying,
i heart failure,
t, etc. It means
ease, or compli-
which caused
iitions, if any, 1
h r gave rise to I
k cause (a), r
a g the under- 1
S> cause last. '
C editions contrib- .
g o death but not
!e to the terminal
u condition given
ji.e,
i
63-93631+8
Suffolk
U'Mfotbp
w f (If death occurred in a hospital or institution,
No St. ( give its NAME instead of street and number)
2 FULL NAME.
(C,ty°7rO*W> Avei
Semak Alice ( Vaughan. ) Fo/idaith.
$ljp (Unmmmuitpaltli of fSatfHarljuflrttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
29
Registered No.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Permanent Residence. No. 7^ O/UondoAve St
(Usual place of abode) _ _
Length of stay: In place of death. .*r....years.*e months days. In place of residence.. years. ..rr.. months days
PHYSICIAN — IMPORTANT
No
L I O
(i
(Was deceased a
U. S. War Veteran,
f so specify WAR)..
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
T!;&vF pcs 3 /itrl
(Month) (Day) (Year)
4 I H E R
I)„Y C
19....'
I last saw ive on
J I F Y
to..
That I atteaded deceased from
£..lZr£...Z?...^*mr.., 19«UL
19^.-)death is said to
have occurred on the date stated above, at
8 SEX
9 COLOR
Female
Itikite
INTERVAL
BETWEEN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE ONSET AND
(a)
Due
(b)
'/cnci/L#* fct'Z
Due
(c)
OTHER
SIGNIFICANT
CONDITIONS
tzz..
Was autopsy performed? .
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of decease
If so, specify
$0
(Signature)
•> >?-/£<
wu s l
(Address)
M. D.
Ll9.
43
Fonj&si Date Malden, /'load,
' " ~ tion (City or Town)
Feb* 6 ,,,65.
Place of Burial or Cremation
DATE OF BURIAL
7 NAME OF
FUNERAL
ADDRESS
Received and filed
(hanle* £./>. MasvgeAon
Si Malden, Moaa.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED (iljfj.-,..
DIVORCED™*'0***’’
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(or) WIFE
Hojuuj. tf'’Po&dm.' 1
in full)
(Husband's name in full)
12 85
AGE \ ears Months Days
Hotel MqAo
If under 24 hours
Hours Minutes
13 Usual
Occupation
(Kind of work done during most of working life)
14 Industry
or Business..
StandLdk Hotel, Uo/icejteA, Moum.
W5-t6^8?78 "■
15 Social Security No
16 BIRTHPLACE (City ) Hunted ( tiU N.S
(State or country) v a
H
£
W
IK<
o.
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
(jeange B. Vaughan
~fcX
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)..
(State or country)
fingeline <// veenougk
Its.
21 Informant
(Address)
Mgna /hunman
7k Onlando Ave. Uinthnop, IAiaa.
I HEREBY CERTIFY that a satisfactory standard certificate of death
/gs filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
(Signature of Agent of Board of Heaith or other)
'... f. :..... ( i 1.
(Official Designation} (Date of Issue of Permit) 1
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose 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.
-T-
FORM R-301
ed for burial permit
t) Board of Health
Ir its Agent.
liTRUCTIONS
FOR
II IL CERTIFICATE
I T OR TYPE
3 OR CAUSES
C DEATH
i not enter
m e than one
:a.e for each
(i, (b) and (c)
suioes not mean
i de of dying,
heart jatlure,
!H etc. It means
di lse, or compti -
mj which caused
h.
mi ions, i) any,
nil gave rise to
>m cause (a),
ali the under-
in, cause last.
Ctlitions contrib- .
t death but not
ed o the terminal
se ondition given
t).
Ui2-931tS53
aM
< Suffolk f A4'
P (County) \^/l/
Winthrqp ' ^
(City or Town)
(Hommnnuiraltlj nf HHaaaarliUHFttjB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
...Iin.t.hr..o.p.., Mass..*
(City or Town making this return)
Registered No.
m
No..
,.B.ayYi.e.w. Nux.s.lu^.....Ho.Me. sJ(If death in a ■ho?p,,al or
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME... Ruth. Melia. H.e.n.r.ic.ks.en S ■ W i mm- ) /(Was deceased
(If deceased is a married, widowed or divorced woman, give also maiden name.) \ U. S. War Veteran,
vif so specify WAR)..
No
(a) Residence. No.. 281 Princeton St Eas.t. B.o.a.t.o.n.* Maas..*
(Usual place of abode) (City or town and State)
Length of stay: In place of death years..2.... months l.ttfcys. In place of residence 5 Q> ears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
(Day)
(Y ear)
4 I HEREBY CERT IF y . That i attended deceased from
19.6s:...
I last saw haKjal ive on ..^7 w.bf.ii, death is said to
have occurred on the date stated above, at ....S\, 6b.... .m. INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
B.r OMC ti a
Due
(b) .
^M^oCAKOiAL HlARI i)±$'
Due To
(c)
SIGNfFICANTC./^..^..^..0..(?.^..^......T..^..^.^.^.d.<3ie.^S..
CONDITIONS
i~ y j
Was autopsy performed? :1>leCt...
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? lu
If so, specify
(Signature)
... M. D.
^ . (Print or Type Name)
(Address) l6././.A/..J'..tt..R..Cf...l6. i*JDate./h/5r
.#*/.. 19. ,4.J~
6 .....Wo.od.l.aym Q.em.e..t..e.ry. Everett
Place of Burial or Cremation (City or g
date of burial E.e.bniagy .6. 19....6.5
7 funeral director ...Alfred B.* Marsh
199 Wintjrrp St. Winthrop,Mass
ADDRESS
Received and filed
FEB 8 1965.
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED
Di™Tcl3aarI'ied
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Thomas Willi.am,...H.enr.i.ch.s.stn.
(Husband’s name in full)
AGE 6.7y e
5. ..Months.. 26 Days
If under 24 hours
Hours Minutes
13 Usual
Occupat
ion f7/hQ%e.daTa... Mil linlry Store
(Kind of work done during most of working life)
14 Milliner
15 Social Security No... 01.1 05 929.6
16 BIRTHPLACE (City). ...-£
(State or country)
East Boston, Mass.
17 NAME OF
father Herbert M. Swimm
18 BIRTHPLACE OF >T ~ ,
father (City) In o v a Scotia, 0 a n a d. a
(State or country)
19 MAIDEN NAME
of mother Amelia Van Norton
20 BIRTHPLACE OF _ .
MOTHER (City) P.Q.r.t C.ly.US .NQ.YR.
(State or country g Q Q t j a f G Onada
2 1 Informant Thomas E* Henri cks.eii .
281 Princeton St.
(Address) .. ffass;
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fifed with jpe BEFORE the burial or transit permit was issued:
fM, _
rfl I- j./9(t>±
(Official Designation) (Date of Issue of Permit)
A
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING ,
ORGANIZATION AND OUTFIT
SERVICE NUMBER
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.
/ j
Statement of Cause of Death.— -Physicians : see explanatory instruction's-
on face side of standard certificate of death. /v :
Vp,
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 pifisjiess,
report the kind of work done during most of working life even if retired- UhlF"
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.
ri-JS
.
8/365
J M
t»n
R-301A
UCTIONS
'OR
CERTIFICATE
giving
3F DEATH
»t enter
than one
for each
b) and (c)
si not mean
o ) dying,
tear! failure,
tc. ft means
, or compti- ,
hich caused
ti, if any, )
we rise to I
ause (a), f
he under- l
ause last. J
E
H ions contrib-
t talk but not
I the terminal
edition given
! Chapter 137,
i 1954, requires
:ns to print or
e cause or
>f death on
■ tificates, and
• 48, Acts of
■ luires Phvsi-*
t prints rftybe
iler^fgnltu*.
■) ^ ^
>28145
M GIfj? (tfommnnuiraltlj of iHaflaarfjuHrttfl
1 ’ Ur " 1 U VV 1 JOSEPH D. WARD
2 SojColK
“'f bounty)
31
(U.
\o
/til
I'-1
<
J
\flu
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
OSTOH STANDARD ( ) 1 45f>
v or Town)- CERTIFICATE OF DEATH Registered No.
WO P I i\ /v evs n ft ^ f (If death occurred in a hospital or institution,
t.9A._.V±g&a St. i give its NAME instead of street and number)
No.
<^~"N q /\ . PHYSICIAN — IMPORTANT
\J l Ct f-i l 0 f(Was deceased a /
2 FULL NAME CZ.Y.Z. T \*. .....1. \ U. S. War Veteran, A
(First Name) (Middle Name) (Last Name) (if so specify WAR) r V Le
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual place
5.4 Q> u> nc ^
of abode) J
..St.
Clf nonresident, give city or I
town and State)
Length of stay: In place of death (.j.. . years.. . months days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF U. A /.
DEATH 4?
(Month) (Day)
i3Ar...
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
jA.Ly. igST-t:., to ’%*&...(». » CaC
I last saw h.Urvalive on , l9...(frC., dtath is said to
have occurred on the date stated above, at . sSCt 2 7. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
Pol l
cm
Due To
(c)
y Cm phy^'tyiti-
OTHER
SIGNIFICANT
CONDITIONS
.J2Ckx&.**L&
Was autopsy performed? ZEE
What test confirmed diagnosis?
INTERVAL
BETWEEN
ONSET AND
DEATH
yrs
As
5 Was disease or injury in any way related to occupation of deceased? 7 PT
If so, specify
(Signed)
Q\.
rrY...
i nt o:
A
M. D
(PRINT OR TYPE SIGNATURE)
(Address) Date ...7^d.-...7 19^-
6
Place d! Burial or Cremation *J (flity or Town)
DATE OF BURIAL 19. f ?
7 FUNERAL DIRECTOlT"""^(^.£.^^(J.f^.®^(....^?..^T.Vr.....sff£T.A..C...'...
yPl^aL
ADDRESS
Received and filed bl
/*W.V .fy.AJ.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
71 die
9 COLOR
OaJ K \ ref
10 SINGLE (write the word)
MARRIED
WIDOWED , i
or DIVORCED \X> \Op uK?Q
10a If married, widowed, or divorced s? i • . I
HUSBAND of }... A$±x.r\...
(Give maiden 'name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE§§.
Years ...Months Days
If under 24 hours
Hours Minutes
13 Occupation: JZQR.Z.XK.dM
(Kind of woA done during most of working life)
“ “SK,.,: goal ‘Business
15 Social Security No ... a../±u:
16 BIRTHPLACE (City) .
(State or country)
17 fatherf /V oc ho m ^ R K izj
^^UsTTfi^
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
h <J fl fj / € ^ ‘
USS/&
jSA.mM.ei flPrJlLq K.
CO a t r) ^ A t; -e. -KJ i r\ ~ I\]Lqj£
dUx-
IniprmAnt
ydrJss)
i/hereby CERTIFY that 7sa))fsfactory standard certificate of death
(as filed with me BEFORE tile tAirial or transit permit was issued:
'UcrlS. ..:
(Signature of Agent otZBp ard of^Healtl^ or other)"
cC /-M J
(Date of Issue of Permit)
^ffrCial'TJesigna^fon)
Y.
^ TRUE COPY ATTEST:
$
(/ City Regisvrar
—
r • 1
■. = J
ivH
FORM R-301
•d for burial permit
Board of Health
' its Agent.
iTRUCTIONS
FOR
tl CERTIFICATE
T OR TYPE
| OR CAUSES
DEATH
not enter
e than one
ie for each
, (b) and (c)
iidoes not mean
I fde o f dying,
| heart failure,
I. etc. It means
mate, or compli- ^
I which caused
iions, if any,
' gave rise to
cause (a),
I' the under-
I cause last.
iditions contrib- ^
death but not
:d o the terminal
ie ondition given
r
I "K — t
*
2-932382
K ,x
IS Suffolk...
(County)
..Wi.nt.hrop
(City or Town)
ulljr Cftnmmmtuifaltlf of fHaaaarijUBPtta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
: 32
Registered No.
1 li o 4. _ +. t (If death occurred in a hospital or institution,
No 1 rr.....SC yiH.Q.Ur. O tr 6CJD. St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME MOHS B D.Uf.f.y.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
) U. S. War Veteran,
l.if so specify WAR)..
No
(a) Residence. No l4.....S.ey.mQ.ur. Street st
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay : In place of death3-.5years months days. In place of residence3-5years months days.
MEDICAL CERTIFICATE OF DEATH
3deathof. February 6, 19.6.5
(Day) (Year)
(Month)
4 I HEREBY CERTIFY, That 1 attended deceased from
1.1-21 19...5..2. to...2.-.6.-6.5. 19.
I last saw ne.Eii ve on 2.— .4 , lfi„5., death is said to
have occurred on the date stated above, at 1 a » m. INTERVAL
BETWEEN
ONSET AND
DEATH
5days
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Bronchopneumonia
(bflTl. Pa ?ki ns on ’ s disease
(c)e Ge ne r $ 1 i zed_ ar t e r i o-
-scleros is
significant A.5t.©rioscler_pt ic^
conditions disease
9yrs
13yrs
Was autopsy performed? no
What test confirmed diagnosis ? clinical & lab
lOyrs
5 Was disease injury in any way related to occupatioi
If so, specify l.
at injury in any way related to occu]
of deceased ?
(Signature) f , M. D.
M«Traunstei.n , .Jr - .
(Address)
73 Bar?fi?£^S“L2=6- ,65
Wihthr op /Has s
6 Winthrop. Mln.thg.Qp Mas s
Place of Burial or Cremation (City or Town)
February 9, 1965
DATE OF BURIAL
7 NAME OF . ,, T ^ n
funeral director Arthur J , GlMaley..
ADDRESS
Winthrop , Mass
Received and filed
FEB 81965
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
widowed Mar r* i ed
DIVORCED aI L -LCU‘
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(or) The text goes on. The rest is in the file.