The volume, 1966
Town Clerk, Winthrop · from the Internet Archive · 510 pages · 32.4 MB
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FORM R-301
filed for burial permit
h Board of Health
or iti Agent.
INSTRUCTIONS
FOR
IICAl CERTIFICATE
:INT OR TYPE
ISE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
(a), (b) and (c)
his does not mean
mode of dying,
t as heart failure,
enia, etc. It means
disease, or compli- ^
ons which caused
•h.
onditions, if any, 1
hich gave rise to I
hove cause (a), r
'ating the under- l
ling cause last. "
Conditions contrib- .
ig to death but not ^
ted to the terminal
ase condition given
(a).
'M 2-62-932382
(Hmmtumumtltfj nf fHaaHarljuflfttfl
O ■. V <£\ KEVIN H. WHITE V
■o .. , Secretary of the Commonwi ,uh
2 FULL NAM E. <>/. ..»■.-
STANDARD
CERTIFICATE OF DEATH
r-3 >rrr
WINTHROfr
(City or Town making this return)
1
1
Registered No.
((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(If deceased is a^nrarried, widowed or divorced woman, give also maiden name.)
.. j (Wa
)u. S
V. if sc
as deceased a
S. War Veteran,
^...AA...^.^..f^d..
ace of abode)
Length of stay: In place of death years months.X/days. In place of residence,^#. years months days.
so specify WAR).
HjWj
(a) Residence. No..
(Usual place of abode)
St „ _ ,
(If n^rfresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
DATE OF \ . , . I l I
DEATH ...X. V
(Mctnth) V (Day) (Year)
4 I HEREBY CE R T I F Y
..5DaUC, 19...fe.S. : , to....h^.OW.*i. .V
That 1 attended deceased front
19. 'oC
I last saw h.v.VMive on , 19...V$ death is said to
have occurred on the date stated above, at ..n.’..!$.f-..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) NjLrvft.VAA.^.
Due
(b) .
. 1 .5?. . ^T. . .
Due To
(c)
OTHER
SIGNIFICANT'
CONDITIONS
T
INTERVAL
BETWEEN
ONSET AND
DEATH
>^fs
Was autopsy performed? Ho...
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceasedKt^..
If so, specify
(Signature)
. -4,
6 ....C.&3zX.C.r Cz*X..
Place of Burial or Cremation
r (City or 1 own)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
AL
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN,
(write the word)
11 If married, widowed, or divorced
HUSBAND of (A..
(Give maiden name of wife in full
(or) WIFE of
(Husband’s name in full)
12
AGE
Years.. iT Months.,
f/L.
Days
If under 24 hours
Hours Minutes
13 Occupation
(Kind of work done during most working life)
14 Industry 3^
or Business
*
t; ■ L-k- l- -t.--
15 Social Security No
‘ , :
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
isAuuLLL
A
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Jt
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
r>
Mi
I HEREBY CERTIFY that a satisfactory standard certificate of death
filed with tpe BEFORE the burial or transit permit was issued:
O
,. t±fc.l. -
(Signatur^of Agent en Board of Health or other)/ /
£■ / /\3 /
(Date of Issue of Permit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION y
DATE OF ENTERING MILITARY SERVICE .Z?.£/..L
DATE OF DISCHARGE
RANK, RATING ,r ... ^
ORGANIZATION AND OUTFIT *?..&£.:
SERVICE NUMBER ^../££.£.£.J..\:.Z.
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 oyer. 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.
. HV 9SSI. £ NVr
ORM R-301
or burial permit
ird of Health
a Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
not enter
: than one
e for each
(b) and (c)
foes not mean
ie of dying,
heart failure,
etc. ft means
ue, or compli- ^
which caused
ions, if any,
gave rise to
cause (a),
• the under-
cause last.
ditions contrib-
death but not
o the terminal
condition given
rid), fit.-
6 5-939763
4
Glljr (Eummmuuraltfj of fUtanaarfjufiEttB
< Suffolk
W
fi (County)
1 ' ° Win th ro p . Ma ss .
[j (City or Town)
j „ Winthrop Community Hospital
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
WNTHROf.
(City or Town making this return)
o
Aw*
Registered No
2 FULL NAME
.......... w r __ I (If death occurred in a hospital or institution.
No :. P “ St. | give its NAME instead of street and number)
y PHYSICIAN — IMPORTANT
Hannah G r e e n h u t
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a I /
) U. S. War Veteran, ZJ k
\if so specify WAR) (..r.Y...
(., P.™.™., Residence. No. ..!! Jj?i MH T_ A V E . S, W'"™RQP, MASS.
, (City or town and State)
Length of stay: In place of death years months... f.jMnys. In place of residence./^...years months days.
3 DATE OF -f® A A7
DEATH /V
(Month)
MEDICAL CERTIFICATE OF DEATH
7J6Z.
(Year)
Jl
(Day)
4 I HEREBY CERTIF Y . That I attended deceased from
2 Ta k i9..y 3 +_io ^ ...... _ , 19.4.6....
I last saw htfJCalive on -j a y\x yt 19..^P death is said to
have occurred on the date stated above, at y,‘at>A .A....m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Jjrjelo j? hx) ^i‘5 v
n... t,x "
Due To
(b) .........
Due To
(c)
SIGNIFICANT^.^. Vl ? «/ V.€ki 0U4 / «f- jp//
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
fcnfrl-C
uvh/re-
10 SINGLE (write the word)
.MARRIED
WIDOWED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.s w>.4?..M.t?..£l/. (&x..R£,.e,HM.UZZ.
(Husband's name in full)
vs,
VSs
Was autopsy performed? f
What test confirmed diagnosis? (UiMiCAl.
S Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature)
Qjhjthrrdl^
M. D.
CMAJSxjES. isi .AM. I.R...M.A.A/...
(Print or TYP* Name) / - / , ,
(Address)t't)/./V..T*^ Date..../...^L...~i Siyt. 19.4.4.
r..
Place of Burial or Cremation
DATE OF BURIAL
'-U-
U-\ Hf/
(City or Town)
7 NAME OF
FUNERAL DIRECTOR
A TRUE COPY A!
I Registrar)
12
AGE U. ^TVears Months Days
If under 24 hours
Hours Minutes
Occupation.
(Kind of work done during most of working life)
15 Social Security
. N o ~'Z3 ls
16 BIRTHPLACE (City)..,
(State or country)
17 NAME OF
in /\i>i r. ur /
FATHER
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
(
JU
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
(b iM K.(jC>wu\
21 Informant .1?
(Address)'
Kcfzr Cr&mMpT-
Skit. Hr 2 Ms
I HEREBY CERTIFY that a satisfactory standard certificate of death
filed with me .BEFORE the burial or transit permit was issued:
- « (Signature .of (Agent of Board of Health or other) / / /
(Official Designation) 1 (Date of Issue of Permit)
0./c*
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
'JM-Si£B6 Ffl
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
ed for burial permit
P ird of Health
Agent.
NSTRUCTIONS
FOR
CAL CERTIFICATE
NT OR TYPE
5E OR CAUSES
5F DEATH
do not enter
tore than one
auie for each
a), (b) and (c)
il does not mean
mode oj dying,
oj heart failure,
nia, etc. It means
tisease, or compli- ^
is which caused
iditions, if any,
ich gave rise to
ive cause (a),
ting the under-
ig cause last.
Conditions contrib- _
to death but not
d to the terminal
te condition given
-12-62-931*553
(HflmmmuuEaltlj of HaaaarfjuHEttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WNTHROf'
(City or Town making this return)
(<j (City or Toum)
X
STANDARD
CERTIFICATE OF DEATH
2 FULL NAME.
Registered No.
.'5
((If death occurred in a hospital or institution,
St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(a) Residence. No.
(Usual place o'f abode)
) (Was deceased a j S
) U. S. War Veteran, //' ,-t
(if so specify WAR). ./ f. ...C'.
..St..
%
4JA...
(City or town and State)
Length of stay: In place of deat1 ai> u.mi.n- Pay;-. In place of residence years.. months days.
3 DATE OF
DEATH ....
MEDICAL CERTIFICATE OF DEATH
CpW'
(Month)
(Day)
i/f (e Jp
(Year)
■4 1 HEREBY CERTIFY, That 1 attended deceased from
*A.A/S/.., j_to A/ i. 19 ^ b
I last saw h^K alive on .. ~_i„ Q FY' » , 19.^.£, death_ i s said t<>
have occurred on the date stated above, at A
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) il&iY o tv*, y.h ixt*<Uu s, ion. s
Due To
(b)
y o ) \a rsj. fad*
Due To /l
(c) /T
fi.y. .^y..hcMS.i\Ayi Pm../ f m ('jtil ) (j u
4 xV £ ('ll o 5 e / ev oS } 5 I
CONDITIONS^ Ffr ^
rs .
INTERVAL
BETWEEN
ONSET AND
Was autopsy performed? .... s ,
What test confirmed diagnosis? (I Llna^A L
yoyrs
(JY
5 Was disease or injury in any way related to occupation of deceased CAL
If so, specify - — / U
(Signature)
-2 . .w^rr. , M. D.
(Print or Type Name) * /
(Address^../.^.Z!6f.^.fl.^..^/..^.jS!^..Date iy...^..I..... I9.(l..b.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
// 0 (Give maidg
0 (Husband’s name in full)
(or) WIFE of..
naidw name of wife in fuBF J
is&r.:..
1 2
AGI
~n
ears V< Months^* ^ Days
13 Usual
Occupation .
If under 24 hours
Hours Minutes
(Kind of work done during most of working life)
14 Industry
or Business.
15 Social Security No
16 BIRTHPLACE (City).
»(State Or c ountry )
Li i‘L
17 NAME OF
FATHER
■£&
)YicL4l4Ls
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) (/.... A to,.
(State or country)
I HEREBY CERTIFY that a satisfactory standard certificate of death
j)wav)file4 with mtf’BEFQtyE the burial or transit permit was issued:
A TRUE COPY ATTES’
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 ^h^^cisn-' is’ ' f'Q
absent from home when the certificate of death is needed. -- I • JO
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
DRM R-301
jr burial permit
rd of Health
i Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
not enter
: than one
t for each
(b) and (c)
toes not mean
ie of dying,
heart failure,
etc. It means
tie, or compli-
which caused
ions, if any,
gave rise to
cause (a),
the under-
cause last.
lilions contrib-
death but not
o the terminal
on dilion given
65-939763
(Hmmnmiuiraltlj of HlasaarijUHrttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHKUE
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
C
< So fioi £
G I (County)
or'Dowh) I /7«8F' i n ion i i_ wr i n
j tt03.pl ..Aft../ S,.|(g,vdeei:.,sNCAUMrrEe1ns
J PHYSICIAN — IMPORTANT
jLL.L ( (Was deceased a . /
ed or divorced woman, give also maiden/name.) - j U. S. War Veteran, /// A
j. j \ if so specify WAR)
!</ }r/ts A/ A J/.... 5. .s, yl / h^hteof^
2 FULL NAME.
in a hospital or institution,
nstead of street and number)
OS...A.
(If deceased is a married, widowed
(a) Permanent Residence. No.
Length of stay: In place of death years months.A«Ldays. In place of residence years
'(City or town and State)
months days.
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
(Month)
7
(Day)
/Uk
(Year)
4 I HEREBY CERTIFY, That 1 ,attemled deceased, from
, 19.6 io 'j... I9.®d®„
I last saw h. cfL ive on .. 7 19. death is said
have occurred on the date stated above, at fr.&rrTl . . m. INTERVAL
BETWEEN
ONSET AND
DEATH
W/C\‘
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To/>
(b)
Due To
(c)
vl> fteTtt/o yCL0UTte /¥%
CP
OTHER _ _ _ - ^
SIGNIFICANT \Vy*7t- £ p.\.\/.<UfcAl.i.
Was autopsy performed?
What test confirmed diagnosis? ... C.U.A.j..C..A.(rrr:
lulu
5 Was disease or injury in any way related to occupation of deceased
If so, specify
~7tu
(Print or
(Address)
(Signature) , M. D.
M...:
- -- - Name) n
r.^r^-.-Date JAtflt.7... AA.
.. i.
Place of Burial or Cremation (City or Town)
DATE OF BURLAfc-^- 'J...A....H...1 /.A. 19*£.£f?
7 NAME OF
FUNERAL DIRECTO
ADDRESS
ol {^Ec/f..^
fdli... ^.AA.^dA.f...
Received and filed I. ...^
1AM 1(1 1966
A TRUE COPY ATT1
i Registrar)
A M/4 U
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
M / /f
10 SINGLE (write the word)
.MARRIED
WIDOWED ' /
DIVORCED \ . />
UNKNOWN J ' r‘ ° ' C.
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 ~ J .Ye
ears Months Days
Mon
C A V
If under 24 hours
Hours Minutes
U Occupation A A « *A Lf..±<?Af..!L..
(Kind of work done during most of working life)
” S'ifflU:.. R.£.h*j..d
IS Social Security No C'n d.33z 3 a-.. A. to A
16 BIRTHPLACE (City)r
(State or country)
'H t A+o A W* rr
17 NAME OF-p
FATHER J rtWlfS
7>
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
7M r As/ rfrYfy
3 6 S />/
TidWiA
l DEN NAME j Jr
MOTHER / Jet/ /yi/1«?7// »/
19 MAIDEN NAME
OF
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
/$ c S^o r/’
Ad ^ S S ,
/A f A.AAAA.A.y
21 Informant W. AAuA. d d J .1.
(Add /Ive. )h*Uty
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me -BEFORE, the/inrfial or transit, permit was issued:
(Official Designation)
b.l i
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
V ‘ .
RANK, RATING .'.&•>?
1 ' ’ '
ORGANIZATION AND OUTFIT
SERVICE NUMBER J.M.i.Q.lwBn.LI.
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.
)RM R-301
tor burial permit
rd of Health
i Agent.
MOTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
tot enter
than one
: for each
(b) and (c)
ion not mean
ie o) dying,
heart failure,
etc. ft means
ise, or compli-
which caused
ions, if any, 1
gave rise to I
cause (a), r
the under- l
cause last. '
iitions contrib- .
death but not
o the terminal
ondilion given
65-939763
X
^ Suffolk
(County)
W I nthrqp
(City or Town)
b
'CW
®lj? (Cnmmmiuipaltij nf fHaaBadjaapltH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
W { NT HR OP
(City or Town making this return)
a
2 FULL NA
Registered No.
No , W l NT^iOP COMMUNITY HOS P I TAL St.
Jack^Casdan
5
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
J (W
)U
U s
as deceased a
S. War Veteran,
so specify WAR)..
(a) Permanent Residence. No. 50 fXARL E . * St WlNTHROP, MASS...
(City or town and State)
Length of stay: In place of death. X ..years months. <3.,days. In place of residence.. ..3 years months. Y^. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF \ ^ , ,
DEATH OL *\ S> QUVsA
(Month) *
%
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
V® 19...V^9 .... to, ^ , 19
I last saw h» y^hve on 4 a lx ..., 19..*J»...\» death is said to
have occurred on the date stated above, at ...V V*L\?..S.(?m.
8 SEX
9 COLOR
10 SINGLE (write the word)
.MARRIED
y/jt-*
W r/ / y A
WIDOWED M A „ _ _ _
DIVORCED MAKfU* £7
UNKNOWN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due
(b) .
&\.eyy
Due T o
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed ?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify . tsYs?.
(Signa
ture) V£v \ ? / c ^ \\ V / l .
m
«-\c\
(Address)
ame) v - \
Date.V IS..
... M. D.
..19^®.™.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 NAME OF , T4
FUNERAL DIRECTOR
A TRUE COPY ATTES-
i Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 7 3
AGE ' 7..V
ears Months Days
TE
If under 24 hours
Hours Minutes
,j ssu.. pjmrf* a.
(Kind of work done during most of working life)
14 oteess:/^ T-J K E A
15 Social Security No..
.a./.'
16 BIRTHPLACE (City). /3 <? $T ?.* , El A S S
(State or country)
.7 NAME OF 1/^. W / A
FATHER / H ' r\
O A 5 OA *
18 BIRTHPLACE OF
FATHER (City)
(State or country)
/? V 5 5 //I
19 MAIDEN NAME
OF MOTHER
y^/ y r 79
e /3 A,
20 BIRTHPLACE OF
MOTHER (City)
(State or country) /? 7 5 5 / /->
21 Informant ..S££.*A€y... CA SDYl/y
(Address) ..Z&..Z A A ,K..j,
I HEREBY CERTIFY that a satisfactory standard certificate of death
s filed with m, BEFORE the burial or transit permit was issued:
ytp. s hle<
tr)
mi
, of Board of Health, or
YtiL?.. /A/a£.....
(Date of Issuo'of Permit)
Ot
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 observ
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 pf
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
vi/n4N>f-'th£ l‘lt1
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.
liA
RM R-301
burial permit
of Health
Agent.
TIONS
OR
IRTIFICATE
OR TYPE
R CAUSES
•EATH
jt enter
than one
for each
b) and (c)
es not mean
o) dying,
heart failure,
•Ac. It meanj
s, or compli- .
mich caused
ns, if any,
a t>« rise to
cause (a),
the under-
cause last.
lions contrib-
lealk but not
Ike terminal
ndition given
1 \o
Std.{{olk
(County)
I'jlnlhtop
(City or Town)
:l m '
® fj* (Cnmmmiuiraltfj nf UtafiflarfjujaeltH
KEVIN H. WHITE
- j Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
WINTHROP,
(City or Town making this return)
Registered No
r>
v-938000
No..
235 t'laia Street
2 FULL NAME
Patpk MintcJvletto
(If deceased is a married, widowed or divorced woman, give also maiden name.)
23 5 Plain Stneet
I (If death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran, w®
if so specify WAR)
(a) Permanent Residence. No.
St..
tlllnthtop
(City or town and State)
Length of stay: In place of death years 0- months days. In place f residence years T* months days.
MEDICAL CERTIFICATE OF DEATH
IJEATh' QxfrUi&U f 10 1 1966
m Month) (Day) (Year)
4 1 HEREBY CERTIFY, That I attended deceased from
19 to 19
I last saw h alive on 19 , death is said to
have occurred on the date stated above, at <m-
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
mate.
wktte.
WIDOWED . /
divorced ma-'rAoexL
UNKNOWN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) gfti ■!* ft v sja j" fc./y. d<i e
(^e..:rofo >:.! 9 hoi'll ,
Due To
(c)
[Vi B
OTHER
SIGNIFICANT
CONDITIONS
(} (■<
tl
INTERVAL
BETWEEN
ONSET AND
DEATH
12 85
If under 24 hours
AGE “ ■' ..Years
Months
Davs
Hours Minutes
TUT
Was autopsy performed ? tl 0
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased wVjL
If so, specify yy /) :..YSr..
(Signature)
-JZ
-tO
u
vUhn* buu&oamfi-*. i/io ju
$t, PilchGet CemeteAuj fioAton
n (City or Town)
tjjayudjaAy 14
6
Place of Burial or Cremation
DATE OF BURIAL
66
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Utncent K. paptno
9 CfieJnea St. ,[aAt %04ton,P1aA4.
~ s'
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced^
HUSBAND of K.04& yiMJAASlO
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
13 Usual
Occupation.
Petlned
( Kind of work done during most of working life)
14 Industry
or Business:
******
15 Social Security No. unknown
16 BIRTHPLACE (City).
(Stale or country)
17 NAME OF
FATHER
0 tottf
Ntcota PlintcJvieUo
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Qtaltf
19 MAIDEN NAME
OF MOTHER Chta^-C PloCeto
20 BIRTHPLACE OF
MOTHER (City)
(State or country) y£CvUJ
21 Informant
RpAe Mtntcfitetto (wife)
(Address)2** Main St. ftlnthbop, PIgaa.
A TRUE COPY ATTEST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
as filed witlwie BEFORE the burial or transit permit was issued:
(Signature of Agefll^ofmpjrd of Health or other)
'..U..lP..£6..^ v
A
(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 Hines's 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 diseaseyj^f^ lated 'tot any^fong pf
injury, have died without recent medical attendance or whose phjrgjciari is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
FORM R-301
d (or burial permij
Board of Health
• its Agent.
STRUCTIONS
FOR
U CERTIFICATE
(T OR TYPE
i OR CAUSES
7 DEATH
> not enter
re than one
ite for each
), (b) and (c)
doe s not mean
ode of dying,
s heart latlure,
a, etc. It means
ease, or compli-
which caused
it ions, ,'/ any,
h gave rise to
t cause (a),
tg the under-
cause last.
nditions contrib- ^ r
o death but not (
to the terminal
condition given
,1.0 ■ s
S3
y
S'
Sv
-63-936348
is Suffolk
(County)
(Urn
... ..Wln.thr.op.
(City or Town)
89 Tafts Are
®l|e (EnmmmtuiFaltJj of fHaaaarliUHPttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
WINTHRQ8
(City or Town making this return)
Registered No.
7
No..
((If death occurred in a hospital or institution,
..St. 1 give its NAME instead of street and number)
2 FULL NAME P.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
) (Was deceased
) U. S. War Vete
V i f so specify W
eteran,
ART.
ww 1
.89 Tafts Ave '. St W inthrop Mass.
(City or town and State)
Length of stay: In place of death. 30 years .months days. In place of residence30 vears months days.
(a) Permanent Residence. No.
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF s-t — At
DEATH .v j /T /V
. ' (Month)
(Day)
It .
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
19 to 19
1 last saw h alive on , 19 death is said to
-n
have occurred on the date stated above, at ..
..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
») 'p.X.CS.Uy u.M.b.lif. cj>LcL
llT—fro kaiuxai. .€.^Li.(2Sy.p.T..a.^.?.i^..
Due To(>< « U gOYOkflfU OCCUs/o>t fr]
(C) .... •‘Ipnz" yiJP 1
<i (c) of
'OTHER
SIGNIFICANT
CONDITIONS
NT aU...iAi kk <?.p
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of decease*
If so, specif
25
(Signature) .^^JL^.sLXsL^. M. D.
(Addre ss
(^rint or Type Name)
) UL..//^lU^.\.GX/.,^.yQ..jg;..Date LfiJkZ.L.Vi.6fc..
6 W inthrop W inthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Jan.1 3
966
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Maurice W Kirby
W inthrop
Received and filed
« f\ f
A TRUE COPY AT
,5113.1966
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
Wh ite
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED
unknown Married
11 If married, widowed, or divorced^ _ .
husband of Margaret E Boughan
(or) WIFE of..
or divorced ,
•st
(Give den name of wife in full)
(Husband’s name in full)
AGE 72 y ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation.
14 Industry
or Business.
15 Social Security No.
Postal Clerk
(Kind of work done during most of working life)
Post Office
025-34-84H
16 BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
Patrick Varley
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Wilton
N.H.
19 MAIDEN NAME
OF MOTHER Mary Mitchell
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Waltham
Mas*.
21 Informant Marga.r&t ..E. Varley
(Address) ^9 Tafts A vo ,W inthrop , Mass
ST:
I HEREBY CERTIFY that a satisfactory standard certificate of death
s filed with me BEFORE the burial or transit permit was issued:
Qy
. (Sjgnajure ai AgeiU/of Board of Health or other)
.... ^ /Tit. . A^/ . .5 .5. . . „ . . ....
(Official Designation) (Date of iiiue of Permit)
^ A/ b-
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE Qfi 7.J. 9.1.7.
DATE OF DISCHARGE Jajo£9#.15t1.9
RANK, RATING S.hau£f.«ur *
ORGANIZATION AND OUTFIT A ^ Corps
SERVICE NUMBER 11 61.6.6?.
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.
RM R-304
In giving
AUSE OF
rAL DEATH
o not enter
ore than one
use for each
of (a), (b)
and (c)
a / or maternal ,
iition causing\
i / death (do |
! use such I
ns as stillbirth I
prematurity.) (
a/ and/or ma-j
i a/ conditions, I
ay, which gavel
e to abovel
se ( a), stating I
underlying /
se /asf.
i ditionsof fetus
mother which
v have contrib-
?d to feta /
fA, fcut, in so
as is known,
e not related
cause given
(a).
4 SEX x
5 COLOR (if
6 THIS BIRTH (Check one)
Male Female.. Undetermined
determined) WH
Single X Twin Triplet
21 LENGTH OF . -
22 Weight Lb. # Oz.J
23 WHEN
DID FETUS DIE?
24 AUTOPSY
PREGNANCY /
OF FETUS
Before
During Labor Y*
completed weeks
(or Grams)
Labor
or Delivery Unknown
Yes No
L0M-6-62-933l».0U
iw Suffolk
(County )
fe
W I NTHRO P
(City or Town
®l]e ContmontoeaItl| of .dMassacfiusetts
KEVIN H. WHITE
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
CERTIFICATE OF FETAL DEATH
(STILLBIRTH)
To be filed for burial permit with
Board of Health or its Agent.
Registered No.
8
rw Winthrop Community Hospital
u No
<
2 NAME OF FETUS S 1 I L L B ° F ►. MALE LAWRENCE
(if given)
g 3 (If death occurred in a hospital or institution,
) give its NAME instead of street and number)
3 DATE OF i . ..
DELIVERY JAN
( Month )
( Day)
966
(Year)
7 IF MULTIPLE BIRTH, BORN :
1st 2nd 3rd
FATHER
8
FULL . w .
name Joseph X. Lawrence
RESIDENCE, NO.
CITY OR TOWN
631 Saratoga
E. Boston
STREET
STATE
10 COLOR OR
RACE
Wu 11 AGE AT TIME OF
w n THIS DELIVERY
HU
(Years)
12 birth OF E . Boston
(City or Town)
Mass .
(State or country)
OCCUPATION PILE DR I VER
14 Ruth ff Jhe§ t o d d a r d
MAIDEN NAME
PRESENT NAME
Ruth R. Lawrence
"is 63 I Saratoga
RESIDENCE, NO.
CITY OR TOWN •• • L0ST0N
STATE
STREET
Mass
16 COLOR OR
RACE
WH
17 AGE AT TIME OF
THIS DELIVERY
34
(Years)
18 birth 0KE- Boston
(City or Ton n j
Mass .
(State or country)
19
INFORMAN
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
(a) How many children are
now living?
(b) How many children were
born alive but are now
dead?
(c) How many previous fetal
deaths of ANY gestation
age ?
25 FETAL DEATH WAS CAUSED BY: IMMEDIATE CAUSE
('YUM** ZM
(a)
Due To (b)
Due To (c)
^•:,v 1
M £Q<V>o t" vL.'no
OTHER SIGNIFICANT
CONDITIONS
Place of
<4^
f Burial
or Cremation
DATE OF BURIAL
(City or Town)
27 funeral director () ). 6* V ^ ^
ADDRESS // -r .
1 M tQCE
egistrar )
A TRUE COPY ATTE
I HEREBY CERTIFY that this delivery occurred on the date stated
above at m., and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner:
. Ji
tvp^;
M.D.
Address
(PRINT OR TYPE NAME)
, Date-T^' ^ ^44.'
I HEREBY CERTIFY that a satisfactory certificate of fetal death
was filed with me BEFORE the burial or transit permit was issued:
( Signature of Ag^/t (pi BoarcLof Health or other)
(Date of Issue of ‘'Permit)
FETAL DEATH
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48,
ACTS OF 1960.
Section 2A. “Examination of records and returns of illegitimate births, or abnormal
sex births, or fetal deaths, . , . shall not be permitted except . .
Section 9 A. When a child is born dead, after a period of gestation of not less than
twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and
no movement of voluntary muscle, the physician or officer attending at the birth of such
child shall forthwith furnish for registration, at the request of an undertaker or other
authorized person or of any member of the familyJ$fl tWMeS&sdd, a certificate of fetal
death on a form which shall be prepared by the secretary of state as required by section
sixteen. Town clerks shall record certificates of fetal death in the town register of deaths
in the same manner as a death certificate, but they shall not be required to record such
certificates in the town register of births.
Section 12. "... No birth record of a child born out of wedlock or of a child of
abnormal sex, and no record of fetal death shall so be transmitted to any other city or
town.”
Section 2U. In any statement of births, deaths and fetal deaths printed by a town the
name of an illegitimate child or of its parents or of the parents of a child born dead shall
not be printed, but the word “illegitimate” or “fetal death” shall be used in place thereof.
A town violating this section shall forfeit to the mother of such child not more than one
hundred dollars.
VI R-303
for burial permit
>ard of Health
it* Agent.
E°3-
?<§o
Uls~-
• " m*
OOi
KZ-S
o< S .
O « to
muiC’’
a
.3^3 «
H< cj;
z5.su
>>■«
4 v H c
5is|
23;?
z . « «
3=-£fe
3 £
f£S.
*u S •
.i|s
>,£t
Jl.£'
Z o «
<■5 o. •>
s* e c
0. o -
! 3.5 i
&
H EH
s«2°5
*.SOoX
-=*
1—1 m'
*
...SUFFOLK
(County)
WINTHROP
(City or Town)
®t)E Commontoealtf) of iHaBsacbusett*
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
WINTHBflP
(City or Town making this return)
Registered No.
i)
Eft route to Winthrop Conraunity Hospital
) (If death occurred in a hospital or institution,
St. 1 give its NAME instead of street and number)
2 FULL NAME ISRAEL ( U^ War Veteran
(First Name) (Middle Name) (Last Name) lif so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.) J '
PHYSICIAN — IMPORTANT
WW I
(a) Permanent Residence. No
5 Coral Avenue , Winthrop
..St..
Length of stay: In place of death years months days. In place of residence. years months days
10
Winthrop
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 dea?hof. January 13 * 1966.
(Month) (Day) (Year)
9 SEX
Male
4 L HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully.)
10 COLOR
\i/hit e
11 SINGLE (write the word)
MARRIED
WIDOWED _• n
divorced Married
UNKNOWN
Coronary occlusion.
12 If married, widowed, or divorced^ .
husband of .J..Q.s.e..pni.n.e .u.o.la.smi.t.h
(Give maiden name of wife in full)
(or) WIFE of
usband’s name in full)
Michael A» Luonco
(Print orTyo^vame)
(Address) ... Boston Date
7Sharon Memorial Park Sharon
Place of Burial or Cremation. (City or Town)
DATE OF BURIAL J&n.UaXff. 1,6 .....19...6.£ =
8 FUNERAL DIRECTOR P.&U.1 R. LeVlDe
addr ess 120 Harva rd St., Brookline
Informant Mrs.*. JosepMne Promise!
(Address)
5 Coral Ave. , Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was Jiled with me BEFORE the, burial or transit permit was issued:
Oy-'" • , (Signatureof Agerft oUlSoard.tjf Healtfi or oth
y/f/t
(Official Designation) (Date of Issue of .
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE 9 /3/XS>.
DATE OF DISCHARGE
2/39113.
RANK, RATING X..3./.C.
ORGANIZATION AND OUTFIT USN
SERVICE NUMBER 155...9&..27
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules
(1) Attending physicians will certify to such deaths only as those of persons to wfrom 4h^'Wave 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.)”
A R-301 A
.
UCTIONS
FOR
IL CERTIFICATE
i giving
OF DEATH
not enter
s than one
e for each
(b) and (c)
s does not mean
t of dying, such
dilure, asthenia, .
eons the disease,
lications which
rath.
bid conditions,
iving rise to the
use (a) staling
ierlying cause
ditions contrib-
the death but not
o the disease or
t causing death.
e:- Chapter 137.
yf 1954, requires
cians to print or
le cause or causes
eath on death
cates.
Suffolk
N -
rV A.,
$.y
(County)
o Win thro p
hj (City or Town)
if
CttommomuTaltlf of UtaaaarlmBrttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
.10...
XG>d Cl 1 f f tlniicoViincimr Hnrofs /(If death occurred in a hospital or institution.
No k±.±.?...t. ?U I.' F St. \ give its NAME instead of street and number)
, PIITI HARRY P. MUNDY , physician - important
2 FULL NAME J (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran, il.0
l if so specify WAR)
(a) Residence. No. ? 64 Oc ean St 'hyntl
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months 1. 1 days. In place of residence 3 years months days.
MEDICAL CERTIFICATE OF DEATH
deathof. .January.... .1.4 *196.6
(Month) (Day) (Year)
41 HEREBY CERTIFY,
That I attended deceased from
January 4 i£6 to.Ja«»ry...M. 1966
I last saw h im alive on January 14 19 66. death is said
have occurred on the date stated above, at 9*45 P m.
DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATH (a)
NG
Bronchopneumonia
ANTE Due To
CEDENT (b)
CAUSES
Generalized
Arterio sclero si 3
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Old Age*
INTERVAL BE
TWEEN ONSET
AND DEATH
3 Day$ l2 p
AGE Q..0... Years rr Months ...4-../
Few
years
Major findings:
Of operations JM.OT1©.
Date of operation Was autopsy performed?
What test confirmed diagnosis? .
No
Clinical Findings
Was disease of injury many way related to occupation of deceased?...*.
-Nb-
(Signed) >
(Addri
vara, Masa+ Date 15 Jan.
6 ....Pine. Grove Lynn Mass..
Place of Burial or Cremation (City or Town)
DATE OF BURIAL . 1/17./66
19
7 funeral DiRECTORArthur... S... Pore el la .
address ..Revere t Ma ss .
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE
MARRIED
(write the word)
widowed widowed.
or DIVORCED* U ^
10a If married, widowed, or divorced . .
husband of. Adelaide ...no t . known.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
1 1 IF STILLBORN, enter that fact here.
10-27 —
Days
If under 24 hours
Hours Minutes
13 Usual
ocxuUion: ...Het i red - . Shoe Manf . .
(Kind of work done during most of working life)
14 or d Busmess : . . . S ho e Findings.
15 Social Security No.
16 BIRTHPLACE (City)..
(State or country)
Nova Scotia
17 name of
father william Mundy
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
of mother Louise
Not known
20 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
Nova Scotia
21 InformantP.r.eS tpn T.» MM.I
■ (Address) ._Xq? El'll 1 CO tt AVe,
Revere.
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE thecburial or transit permit was issued:
Jf (Signature oCXgqnt/il Board etfjlealtb.pr other)!
.
moL--.- 1 x'*--1 ' (Date of Issue of Permit)
(Official Designating)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one, where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town wfhere 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 pf 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 w'ho is a member of the board
of health, or employed by it or by the selectmen for the purpose, shaU 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 ot 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 towm 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 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 d^ath 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 resultihg irtjufy fiy^nfijMion related to occupation,
the sudden deaths of persons Mbt'disdbldd iKyU^cognized 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 knowm. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER .
RM R-304
In giving
cause OF
TAL DEATH
lo not enter
core than one
ruse for each
of (a), (b)
and (c)
Z
a/ or maternal,
idition causing \
ill death ( do
t use su c h i
:ns as stillbirth /
i prematurity.)
' al and/or ma- /
91 al conditions ,
ny, which gavel
e to above ]
ise (a), stating
i underlying j
. se last. -
Editions of fetus
mother which
v have contrib-
? d to fetal
th, but, in so
as is known.
|e not related
cause given
(a).
10M-6-62-933h0b
‘u SUFFOLK
(County )
i <Q Winthrop
(City <rr Town)
®lje CJomnumfoealtlf nf ^Massachusetts
KEVIN H. WHITE
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL. STATISTICS
CERTIFICATE OF FETAL DEATH
(STILLBIRTH)
To be filed for burial permit with
Board of Health or its Agent.
Registered No.
it
'5 no. Winthrop Community HosPital
CL
2 name of fetus Baby Boy Paci
(if given) "
i( I f death occurred in a hospital or institution,
give its NAME instead of street and number)
3 DATE OF
DELIVERY 1
(Mo
I Month )
(Year)
4 SEX
Mal^ Female Undetermined
COLOR (if ti) 6 THIS BIR^H (Check one)
determined) rV Singlet^ ..Twin Triplet
7 IF MULTIPLE BIRTH, BORN :
1st 2nd 3rd
FATHER
8
FULL
NAME
Philip Paci
STREET
residence, no. 425 Saratoga St . ,
city or town East Boston state Mass,
10 COLOR OR
RACE wh
11 AGE AT TIME Fit* _
THIS DELIVL. Qg^ears)
12 PLACE OF ' "TTosT on
BIRTH ,CilfeP» or country)
13
occupation Welder
MOTHER
14
maiden name JosephineVella
present name Josephine Paci
15
STREET
residence, no. 425 Saratoga St.,
city or town East Boston state Mass.
16 COLOR OR
RACE Wh
is place of ... Boston
birth DWisferop, Mass ,
(City or Town i 1 * (State
17 AGE AT TIME OF
THIS DELIV
38
ears)
or country)
19
informant Philip Paci
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
/
(a) How many children are
now living?
(b) How many children were
born alive but are now
dead?
(c) How many previous fetal
deaths of ANY gestation
age? ifc
21 LENGTH OF
PREGNANCY
completed weeks
22 Weight
OF FE
(or
2u>. —
:tus
Oz.
Grams)
23 WHEN DID FETUS DIE?
Before^'' During Labor
Labor or Delivery
Unknown
24 AUTOPSY uW
Yes No ^
25 FETAL DEATH WAS CAUSED BY: JMMED,
(a)
Due To (b)
Due To (c)
E CAU.SE
OTHER SIGNIFICANT
CONDITIONS
(JJoocUxuun Cem.eJ~.eAAj i ueA^tt
Place of Burial or Cremation
DATE OF BURIAL
311
^XiyUdXi/Uj 18
(City or Town)
19
66
NAME OF /T*. /}ty> „ _
FUNERAL DIRECTOR -
ADDRESS
A TRUE COPY ATT(
I HERE
above at
w^pz
IFY that this delivery occurred on the date stated
and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner:
M.D.
(PRINT OR TYPE NAME; J
JF' To .
Address
I HEREBY CERTIFY that a satisfactory certificate of fetal death
was filed with me BEFORE the burial or transit permit was issued:
( SignaUire^L^f^r^d Bo^mI of Health or other)
I b J*
(Officiab'Designation ) (Date of Issue /of Permit)
FETAL DEATH
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48.
ACTS OF 1960.
Section 2A. “Examination of records and returns of illegitimate births, or abnormal
sex births, or fetal deaths, . . . shall not be permitted except . . .”.
Section 9 A. When a child is born dead, after a pdiuodj c^ jj|€^$on of not less than
twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and
no movement of voluntary muscle, the physician or officer attending at the birth of such
child shall forthwith furnish for registration, at the request of an undertaker or other
authorized person or of any member of the family of the deceased, a certificate of fetal
death on a form which shall be prepared by the secretary of state as required by section
sixteen. Town clerks shall record certificates of fetal death in the town register of deaths
in the same manner as a death certificate, but they shall not be required to record such
certificates in the town register of births.
Section 12. . . No birth record of a child born out of wedlock or of a child of
abnormal sex, and no record of fetal death shall so be transmitted to any other city or
town.”
Section 2U- In any statement of births, deaths and fetal deaths printed by a town the
name of an illegitimate child or of its parents or of the parents of a child born dead shall
not be printed, but the word “illegitimate” or “fetal death” shall be used in place thereof.
A town violating this section shall forfeit to the mother of such child not more than one
hundred dollars.
ORM R-301
or burial permit
rd of Health
■ Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
not enter
: than one
e for each
(b) and (c)
foes not mean
ie ol dying,
heart failure,
etc. It means
ue, or compli- ^
which caused
ions, if any, 1
gave rise to I
cause (a), r
the under- l
cause last. '
ditions contrib- .
death but not
o the terminal
:ondition given
65-939763
Gty? (Enmmmtuiraltlf nf HJaiiaarfjufirttH
(City or Town)
No..
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHROfc
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
Suffolk
. (County)
£
Tow/)
il I \t flew ft U fiS/rr^Hcih P ' , „ ((If death occurred in a hospital or institution,
L:...4..y.....k..J..£.W. ......J.. St. ( give its NAME instead of street and number)
r — ‘ , PHYSICIAN — IMPORTANT
Lfllrs/.. Jzz* L../JUJ.. / (Was d<
s a married, widowed or divorced woman, give also maiden name./ J U. S. W'
V if so spe
III (zzAn..^ e.trvL./^j.kL.C...
2 FULL NAME
(If deceased is
deceased a
7ar Veteran,
specify WAR)..
A/d>
(a) Permanent Residence. No.
..St..
Length of stay: In place of death.....fnr.years months days. In place of residence C/^years months days.
(City or town and State)
1
MEDICAL CERTIFICATE OF DEATH
3 \)L\f\)V..-^ LP.. f.jL...L....Q...
(Month) °1 (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
ZJjOLJkx i9...-^3.:rTo....vX^j^--<«-~J^ W-Lfa....
I last saw h£j:alive on , \9.Cjf&, death is said to
have occurred on the date stated above, at m. I INTERVAL
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
nzG~r h
Due To A ^ ,
Due To ’ /
(C) ^...SZ,...yKJ...^../..t.
OTHER
SIGNIFICANT
CONDITIONS
BETWEEN
ONSET AND
DEATH
P2-
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, sp
(Signature),
kf./Ldf.£p../Q.LCz.
(Print of-Type Name)
M. D.
( A d dre ss)ff...ff..L. , L . 1 9
.~AjA.fR. ±£.J../.dAj. ....... .. r> f
Place of Burial or Cremation , ’ (City or Town) v
> (City or Town)
DATE OF BURIAL L.L. 19...Z..^|
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
...Jdl Y.tr...
:L&..... $.(•$. Jk.r.. JMJk OAj/Jej.Ac..
£.J \
i Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
/ thf e/s
9 COLOR
/iL tc
10 SINGLE (write the word)
.MARRIED
WIDOWED
1 1 If married, widowed, or divorced
HUSBAND of
VVIDUWfcD , h ,
DIVORCED fy, J.Wr- /
UNKNOWN '' ' 4
(or) WIFE
r ~) ' / (Give; maiden-name of wife i
of /...../ Aty
(Husband’s name in ful
in full)
fuii)
12
AGE/ (-/...Years Months Days
Ye
If under 24 hours
Hours Minutes
IJ 8EU_ Ay Ac M.c.
(Kind of work dc
done during most of working life)
14 Industry
or Business:
15 Social Security No.
ji.Mt.
16
BIRTHPLACE (City) /Jj.P e.r.A./.i. j.
(State or country)
17 NAME OF
FATHER
/V /.> '
18 BIRTHPLACE OF
FATHER (City)
4-P
riunriv tt-uy; ., __
(State or country) /,J ei
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
AbuipjA —
MOTHER (City) .. J..
(State or country) Af/*£ / J /•/ 7
21 Informant
(Address)
A.Pr./.y .Af.A/.cA/A.A&.
ss) JJ.J PuU /;■ ,e..yj.... A/l (kj#j/A&r
I HEREBY CERTIFY that a satisfactory standard certificate of death
,yj washed with me BEFORE , the burial or transit permit was issued:
LomA ^
. (Signature of Agefit of ___ „. —
^ l ^ ?
(Official Designation) (Date of Issue of Permit)
h.A
of Health or other)
G C
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE JAN [
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
R-302
C ' '
gSU
2 «
u. So
o" -
S-CCO
J=.i!
of«
. c &
■a S<->
V ^
*n O 4>
4> 3
<J 1> o
d£ u
•-££
C
*2f
o £
♦'CM
U° C
07
■Bel
5- ° c
w
*c«
T3 U <U
V £ I
o
3 6 w
U (/> „
SSx
xtr
•- «u <
_ *f* o.
C r-
ir **-■ *■
2 o 2
, E <«
o';
•S-En
U « i
<£t)p (Hmmnmuuraltf) nf MaflHarljUHftta
1 §
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
-■(fifS-fecMGS
g this return)
COPY OF
CERTIFICATE OF DEATH
13
•M Gamhrldii©
tj (City orTown)
,* . , « TT , . _ ((If death occurred in a hospital or institution,
(L No ilrOUQ v ft-Utmi'rl St. | Rive its NAME instead of street and number)
Registered No. . 9&
urre«
ME
2 full name...™.... !A!inthr<3.p......Q.l.e.:,:.als4id^ Horton f <wgs *»•“£
(if so
(If deceased is a married, widowed or divorced woman, give also maiden name.)
War Veteran,
specify WAR)..
(a) Permanent Residence. No 22 34..?W?.F, Sfc* St ^.Ofl.o
(City orAown and^tale)
Length of stay: In place of death years monthsy.^.days. In place of residence.tf.^ears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
i?0(iay^Q66-
(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
19..
to..
?py~" •- 19 $6
I last saw h.^. ..aJive on ^ -O * ^eat^ IS satc*
have occurred on the date stated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE’CAUSE
(a) ...E(D.p..s...ij.?; G C.5..«.^»'. !■.?>.«.. 5.. <3.
Due To
(b)
Due To
(O
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET ANO
DEATH
Was autopsy performed? ..y^iy
What test confirmed diagnosis? Ec,ft rrr-. liven tea ;?s
5 Was disease or injury in any way related to occupation of deceased
If so, specify
M. D.
(Signature) Q.BQ., J.»
h n r n
1 Craigie St. T ,,
•0jS^ Date.x,-^.JTl.^v4.»..f..^90;xJi...
(Address)
«* a
DATE OF BURIAL J «,n r 2 -2L h6&~
7 NAME OF ,
FUNERAL DIRECTOR i*.I..fXfi.& i :...£.r.S.h
address 17.il .....lti.ln.tlir.^o.|3t....iS.t....;: ..l.n.throp..
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
wed, or divo
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed-, or divorced
HUSBAND
(or) WIFE of
(Husband’s name in full)
AGE Years 11 Months. Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
working life)
14 Industry
or Business:.
B..F».fIooflyT ch Go.
IS Social Security No. -Q13-33-7777
16 BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
r >Ay fie pv tile*
Mans «
Ch^ntor Hn^-hnn
18 BIRTHPLACE OF
FATHER (City)
(State or country)
..o.o'jio tsville
"asa .
19 MAIDEN NAME
of mother Annie Robinson
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Dundee
Scotland
A TRUE COPY
ATTEST:
DATE
(Registrar of City or Town where death occurred)
FILED J.an.. 2.1* 19.66.
21 Informant -0 »' i • 0 • » y* t}
(Address) 22. ill rerv St In thr^n ^ e,p p „ ...
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
ORM R-301
for burial permit
oard of Health
its Agent.
TRUCTIONS
FOR
CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
e than one
se for each
. (b) and (c)
does not mean
sde of dying,
heart failure,
, etc. It means
•ase, or compli-
which caused
lions, if any,
i gave rise to
cause (a),
g the under-
cause last.
tdilions contrib- .
o death but not
to the terminal
condition given
•62-932382
Suffolk
(County)
'p Winthrcp
(City or Town)
y'lr
©Ij? ©ammmimwlt^ of fuaHaarljufirttH
2 FULL NAME..
WINTHROF
(City or Town making this return)
'If \ ti
f CERTIFICATE OF DEATH Registered No .-Jr...*...
Cliff House Nursinp Homo J (If death occurred in a hospital or institution,
No St.) give its NAME instead of street and number)
TT ,, ^ PHYSICIAN — IMPORTANT
henry H Brown
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(If deceased is a married, widowed or divorced woman, give also maiden name.)
34 St Andrews Rd.
(Wa
) u. s
V if so
as deceased a
S. War Veteran,
specify WAR)..
(a) Residence. No,
(Usual place of abode)
St.
East Boston
(If nonresident, give city or town and State)
Length of stay: In place of death,,?.... .years months days. In place of residence 3.3... years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
^ f
"iDay)
US..
(Year)
a i , n. r. K t ir i LtKiir i j That I attended deceased from
i9.j6t.3ry t o...c/am>. 2..^ \9.£>A\
I last saw hiMjalive on c/jA.H,.* , 19 Af.df death is said to
have occurred on the date stated above, at .J..(.LQ.Q.&~.. m
8 SEX
9 COLOR
Male
White
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
,pAy^
Tn / — - . ^ - r X
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
hi Airier ^tuii v(
INTERVAL
BETWEEN
ONSET AND
DEATH
6y&]
7 M jee
> y Ks
" n*;;:,.. surgical Supply Co
15 Social Security No Q1 1.-3 6-.Q .2.2 0
i6 birthplace (City) ...W&st Townsend
(State or country) XL13.SS
Was autopsy performed ? „
What test confirmed diagnosis? c.'. Jii'.lV.C./l.h ’^f. tfsTr. . /.I. .
5 Was disease qrSnjury in any way related to occupation of deceased?/)!^
If so, specify ■
(Signature) . I. . / . . 1 . . .4.<r.L<_ . . . .. ...., M. D.
1 °
(Print or Type Name)'
(Address) 7 6.3j*l?TL£T.l..f2h...U6.t(Ai
6 Woodlawn Crenatory 7 Everett
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Jan. 25
66
7 funeral director Howard S Reynolds
Winthrco Mass
ADDRESS
Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Sing
11 If married, widowed, or divorced
HUSBAND of ...
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
AGE j-QQvears. 4 Months Q. .. Days
8
If under 24 hours
Hours Minutes
13 Usual
Occupation : ...Super;m t enden t
(Kind of work done during most working life)
17 NAME OF
father William H Brown
18 BIRTHPLACE OF
FATHER (City)
(State or country) Norway
19 MAIDEN NAME
of mother Mai is s ia Morgan
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Unable to obtain
Alf G Lootz
39 Maple St. Kingston. Mass
21 Informant
(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
TomA £
(Signatjrfe of Agent ok Bbard Health
(Official Designation) (Date of Issue (of Permit)
/fj>£ j1
( s
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
JAn /v ^ I
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physician* will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form ofinjury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
066
FM
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
)RM R-302
Qlfje (EmmnntiuifaltJj of fEaaBarljUflPttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
1 £
COPY OF
CERTIFICATE OF DEATH
w M iddlesex,
Q (County)
S"€a^^^wn)'
No w Ho’3^^' 'M'RTnor’
2 FULL NAM E.......... AjlTlfi J 411*1,0 vP' 1^ tr ft? V Q f ITo-i. 1 ■)•
ed is a married, widowed or divorced woman, give also maiden
(fttp&Sd, this return)
15
Registered No.
j (If death occurred in a hospital or institution,
giy^ NAME instead of street and number)
( (Was
< u. s.
I if so
as deceased a
War Veteran,
specify WAR)..
(If deceased is a marriea, widowed or divorced woman, give also maiden name.)
(a) Permanent Residence. No 44. S> *■ Hpn Road st
Length of stay: In place of death years months....^.yays. In place of residence years months days.
No
State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
Year)
4 I HEREBY CERTIFY, That I attended deceased from
..July-- 19..4J.!....., to Ifl-rn- 2 ]$,•» • 19
I last saw h**.j*|ive on ply- , 19...Zj^Jeath is said to
have occurred on the date stated above, a ^ It * P-ym-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ....Cap«.in©Bia o f the l i ve p
Due To
(b> of the Rectum
Due To
(c)
OTHER
J Aaoite~i« P leura l ; I on
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
12
If under 24 hours
AGB^fy.Years
Months
Days
Hours Minutes
Was autopsy performed ? Fl-Q
What test confirmed diagnosis? Jul']?7 -
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
no
(Signature) ...y. . iliiam j.- Tompkins M- D-
(Address) Q- GOBV» * A VO * Date..l._.pU 19....^
Hos to o — —
6 -Ho l v.- -Cl*OjS R f eiB *
Place of Burial or Cremation
DATE OF BURIAL
n -r .
C em*
ion
i.an... 27*
■ ■C! *
/ *
19....U.L
7 NAME OF — . , , „ -v . . r
funeral director .R.I.ohaj?.d C..„ .I.nc
address .q.1.7. 'Innnln-yfcori gt on
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
'i’wsla
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of .
(Give maiden name of wife in full)
(or) wife of Jo-^Obh piSteB io
(Husband s name in ful
~armlec
full)
13 Usual
Occupation:
worlC done during most of working life)
14 Industry
or Business:
15 Social Security No.
-a-t
16 BIRTHPLACE (City).
(State or country)
*W
oston
— « —
17 NAME OF
FATHER J^cob Hell
18 BIRTHPLACE OF
FATHER (City)...
(State or country)
19 MAIDEN NAME
OF MOTHER
.fip.nanz
20 BIRTHPLACE OF
MOTHER (City)...,
(State or country)
fr 1 1 rU' ’.nc’finan
o rauTi
21 Informant :.J? w :pariki[«-Ot^tasio (son)
(Address) 203 Condor*
A TRUE COPY
ATTEST:
DATE FILED
(Registrar of City or Town where death occurred)
Jan. 25, „ 66 j
Li
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
I°f (c k
ORM R-301
St
for burial permits
oard of Healths^
its Agent. v
rHUCTIOMS
FOR 0
CERTIFICATE ^
: OR TYPE
OR CAUSES
DEATH
not enter
e than one
e for each
. (b) and (c)
does not meats v
4e of dying, *■
heart failure, y,
etc. It means "
ase, or compli-
which caused
lions, if any,
gave rise to
cause (a),
t the under-
cause last.
&
1 ditions contrib-
1 death but not
to the terminal .
condition given
><
*1
63-9363U8
Kb
®ljr (Cummumuraltlj of fHafsaarljuarttfi
Suffolk *
|G (County)
1 lU.
F Wlnthrop
I( j (City or Town)
*• 36 Marshs 11 St .
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
WINTHROP.
(City or Town making this return)
10
Registered No.
No..
K If death occurred in a hospital or institution,
..St. I give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name Charles E Gundersan.
(It deceased is a married, widowed or divorced woman, give also maiden name.)
3 i •? t r t -
J (Was deceased a
| U. S. War Veteran, y tj -1
V if so specify WAR)
36 Marshall St Wlnthrop
(a) Permanent Residence. No.
(Usual place of abode) tl/2.
“22- ~
Length of stay: In place of death years months days. In place of residence years months days.
u
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
j AH t
'•(Month)
J * »••••/ A
(Day) (tear)
4 I HEREBY CERTIFY, That I attended deceased from
19 to 19
I last saw h alive on : * , 19 death is said to
have occurred on the date staged above, at .. c A m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due
(b)
J?Tf g/tfC
...To..fc kai ia.y q, t d-kkS.es * .v
Due To
'(c)
OTHER
SIGNIFICANT
CONDITIONS
IQ VhI kk g b \u jh u h. / / y / fey
:;tz
c C — t- ^
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed ?
What test confirmed diagnosis?
Ac
5 Was disease or injury in any way related to occupation of decease^)^.^
If so, specify
(Signature)
M. D.
B ^ /H AM . .
(Address)
AJdA ,
(Print or Type Name) / / .
6 Wlnthrop. Wlnthrop
Place of Burial or Cremation (City or Town)
Jan .27 1966
DATE OF BURIAL
7 FUNERAL DIRECTOR Maurice W Kirby
ADDRESS
Wlnthrop
Received and filed
A TRUE COPY ATTEST:
13,1, m
( Registrar)
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
Kale
White
WIDOWED
DIVORCED
UNKNOWN
Married
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widow
HUSBAND of
to
divorcecL, _
.0.0 h Cur t is
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
AGE'
f?2
Years.
13 Usual
Occupation .
Months Davs
~U
If under 24 hours
Hours Minutes
Accuntant
(Kind of work done during most of working life)
14 Industry
or Business..
U.S . Arny Eng.
IS Social Security No..
16 BIRTHPLACE (City).
(State or country )
Norn.,
W inthrop
Mass,
17 NAME OF
father Char lea Gunderson
18 BIRTHPLACE OF ..
FATHER (City) ^OrW^J
(State or country)
19 MAIDEN NAME Un,Ou4 dT
UK MOTHER OhdaOWft)
$4
Cl
$
20 BIRTHPLACE OF ^ ~^3"
MOTHER (City) NCUWay J E
(State or country) v3ogt-Q^ (b^ ' ; f
21 Informant
Alice Gund era on
(Address) 25 Marshall St. Wlnthrop ,.Ma s a.
I HEREBY CERTIFY that a satisfactory standard certificate of death
as filed _w 1 1 h^^e^BE^ F OftE^Ut e b^iri^l or trans'* permit was issued:
.was hl<
(Official Designation) (Date of Issue of Permit)
M.
J
T>
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE MjJ.... 1.91.8.
DATE OF DISCHARGE .April .17.. 1919
„ d .
RANK, RATING lya te 1 51. . . st .Depot ..ligate . Army
ORGANIZATION AND OUTFIT hzWJ.
SERVICE NUMBER
2795833
w
r* <-
0
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.
ORM R-301
for burial permit
Sard of Health
ita Afent.
RUCTIONS
FOR
. CERTIFICATE
' OR TYPE
OR CAUSES
DEATH
not enter
t than one
e for each
(b) and (c)
does not mean
4e o I dying,
heart failure,
etc. It means
a se, or compli-
which caused
lions, if any,
gave rise to
cause (a),
! the under-
cause last.
editions contrib- .
i death but not
to the terminal
condition given
-62-932382
K,
(U-ommimuimuj ni MaaflanjuaBitB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WiNIHROt
(City or Town making this return)
2 FULL NAME jU.
(If deci
(County)
inthror
(CiVy or Town) CERTIFICATE OF DEATH Reg.stered No.
- . . 0 TT,vr> c -? ""(-Mvr {(If death occurred in a hospital or institution,
No '. V.iL.-. St. | give its NAME instead of street and number)
/) . O / f rsl . PHYSICIAN — IMPORTANT
STANDARD
CERTIFICATE OF DEATH
'3 ^
JL..«
#4m±C , ( f<»
cfcas^d is a married, widowed or divorced woman, give also maiden name.) j U.
(Was deceased a
U. S. War Veteran, No
if so specify WAR)
, . „ . . M 69 Undine v nue '
(a) Residence. No bt..
(Usual place of abode)
inthropj I ss
(If nonresident, give city or town and State)
Length of stay : In place of death..........years months days. In place of residence -...years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF »r— A ,v I
DEATH +J...../±JSl.,
(Month)
3-s, UAL
(Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
^lA.SrC-M , 19..6..£ to I.^.a 2k.!$L..y , 19./..<r
I last saw h&Valive on , death is said to
have occurred on the date stated above, at .m.
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
Female
t hite
WIDOWED i r ryr rr]
DIVORCED-
UNKNOWN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ...,(2..^y....e...i)...yr^/ J/eut.cx
Due To
(c)
SIG^FICANT^..^./.0.)rt...,
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
^1 rs
2 Hr 5
W'as autopsy performed? ... M.o. „
What test confirmed diagnosis ? ...•£fL^...(...j,l...V...f...i
5 Was disease or injury in any way related to occupation of deceased^..;*.
If so, specify ^
(Signature) -
M. D.
jSJLA£JL£s. Ll3..£.&£L£+ 1.
(Print or Type Name) /
(Address) '^..l.^..J...^...(Zp...tf^.../3cl../KXS^...Daie.....l.../..?...Xy....A9A.C:.
6 doxy Cross Cenet-ery 1(
Place of Burial or Cremation (City or Town)
DATE OF BURIAL L..i...UU.... l.l.J 1966
..19..
7 NAME OF
FUNERAL DIR ECTOR ,«!•. hUXldl
1 1 Sprague St. Revere , Ma s s
ADDRESS
Received and filed
A TRUE COPY ATTEST:
gistrar)
PERSONAL AND STATISTICAL PARTICULARS
1 1 If married, widowed, or divorced
HUSBAND of
- (Gijt'e maiden name of^_wjfe in full)
(Husband’s name in full)
(or) WIFE of..
U 7/ O
AGE1 Years Months Day's
If under 24 hours
Hours Minutes
13 Usual OYlcp' 4 fp
Occupation : it.Srf
(Kind of work done during most working life)
14 Industry . t-_
or Business: ..Qli.
15 Social Security No N.Q.i.IC..
16 BIRTHPLACE (City)...—..,
(State or country ) J.rC-Lc 1"1Q
17 NAME OF
father Patrick Clancy
18 BIRTHPLACE OF -• ,
FATHER (City)
(State or country)
19 MAIDEN NAME , , . _ -
OF MOTHER C 3
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Irelf nd
2. Informant
(Address) qq Umine Ave . V inthror y
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with m,e BEFORE the burial or transit permit was issued:
• £, (fl)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
*/ */**. ~
/ / ,
RULES OF PRACTICE
jMl ■
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.
-d 5 12G6 «H
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.
rORM R-301
Id for burial permit
lloard of Health
its Agent.
TRUCTIONS
FOR
IL CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
re than one
ic for each
, (b) and (c)
does not mean
ode o) dying,
■ hears failure,
etc. It means
■ate, or compli-
which caused
lions, if any,
i gave rise So
cause (a),
g the under-
cause last.
editions contrib-
o death but not
to the terminal
condition given
'/• C-
1
-63-936348
(Enmmonuifaltij nf fHaflaarfyufiftta
.Suffolk
(County)
..Wi.n.thr.Qp
(City orTown)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
..W.intiir.o..p...;
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH Registered No
((If death occurred in a hospital or institution,
[-'7 "Dl <rsooovrl- Q-|--k'qq+ u aea,n occurred in a hospital or institution,
No aT-J^-C-cXO (.dri.L O-.L-l. .C..C...L St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Myra Elizabeth Har.ank.CZepper) / (Was deceased a
* 1 J ’ ’ ' S U. S. War
\jf so speci
(If deceased is a married, widowed or divorced woman, give also maiden name.)
ar Veteran, >T/^
specify WAR).
(a) Permanent Residence. No.
(Usual place of abode)
Pleasant Street st.
(City or town and State)
Length of stay: In place of death T-Oyears months days. In place of residencej-Oyears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T 0 r
death January. 2.6
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
NOV. II 19.6.5 to Jan . 26 , 19.66
I last saw h alive on ... Jan. 24 , ^ 19.66 death is said to
at 3 : 1
8 SEX
9 COLOR
10 SINGLE (write the word)
widowed married
f‘pTB^'1 P
whi t.fi
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
have occurred on the date stated above, at 3. *.4 .: ... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute myocardial in f ar ct lain
i)ue To Arteriosclerotic and hy-
tb) per tensive heart disease
Due
(c)
dfhner.al.ized arte r i o s c | e r o- 4 yr s
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
15 irvjnApE (A, Years ID Months 19 Days
2 yrs
W
Was autopsy performed?
What test confirmed diagnosisC.X.X..D..i.C.a 1 .& Xah.QXTclt O' "Y
5 Was disease or injury in any way related to occupation of deceasedN.Q
If so, specif:
If so, specif/1
ignature)
(Signature) Id r>. ( r~r 1 1 l,‘ t<Kt- 11 .". s .... M. D.
M.. T raunst ein Jr . M . D .
__ (Print or Type Name)
(Address) 7.3 Bartlett R.d . Date Jan . 2719 66
Winthrop,Mass . 02152
& Winthrop Cemetery, Winthrop,Mas ^ i.
Place of Burial or Cremation (City or Town)
date of burial J anuary 2..8.>..1.9..6.6 19.
7 funeral director -Alfred B..» .Marsh..
address 1.7..4. .V/int.hr.Q..p......S..t..........Ei.nthro,p.,,.
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(Give maiden name of wife in full)
(or) wife of...j..o.s.e.ph....Erunk....H.ar.ank
(Husband's name in full)
If under 24 hours
Hours Minutes
13 Usual
Occupation .. Housewife
(Kind of work done during most of working life)
14 ‘^Business DWJl HO.ie..
15 Social Security No... .Q. 2.3 ~ 26-4.32.7- H
16 BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
Hngl and
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
Thomas Popper
19 MAIDEN NAME
OF MOTHER
Wngl end
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
.Mary Taylor
\ngl and
21 informant ..J.QS.e.ph... .1 Har.ank..
(Address)
.5.7 .Ple.aa.ant. S..t..» M.n.t.hr.o.p I
1 "" ■ - ~ - — ■ 1 ■■■ "
Mak§ bled wi(h
[-■jujJL
A TRUE CC
ATTEST:
EREBY CERTIFY that a satisfactory standard certificate of death 1
TEFORE the burial or transit permit was issued:
I
c~\s , tsign^ure of Agent of: Board. of Health or other) /
zSWz J^..A±Alk.k !
ttion) (Date of Issu? of Permit)
0.16, VA / 1
(Official Desi:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RANK. RATING
ORGANIZATION AND
OUTFIT
SERVICE NUMBER
e of persons
disease un-
RULES OF PR
The fulfillment of the purpose of these laws calls
following rules of practice: - -
(1) Attending physicians will certify to sc
to whom they have given bedside care dut<
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 <jf home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
/ >’/v
&A> a.
jfr ^
(County) ' hi;
©fjr (Hmnmmuupaltff nf il0a.0flarf}U8Ptt0
Suffolk
x
H
l<
\w
r
)® W| NTHROP
l(j (City or Town)
U Winthrop Community Hospital
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
pfiNTHROP.
(City or Town making this return)
Registered No.
10
No..
FUL^NA ME^.. ...C.A.I.HE.RJ..N.E.... Smith
(If deceased is a married, widowed or divorced woman, give also maiden name.)
((If death occurred in a hospital or institution,
■St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
J (Wa
\ U. S
\.if so
as deceased a
S. War Veteran,
so specify WAR)..
r/c
466 Sumner Street ^ E .Bo ston , Mass.
— (City or town and State)
97
w * V
(a) Permanent Residence. No St
jT
Length of stay: In place of death years months days. In place of residence years months days
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Feb
(Month)
(Day)
966
(Year)
4 I H EREBY CERTIF Y. That I attended deceased from
....^7 sf 19..6 Cr .... to 2- , viCA
I last saw h^.^alive on ... , 19, .^..^ideath is said to
r i A
have occurred on the date stated above, at O jO ■• m. INTERVAL
BETWEEN
ONSET AND
DEATH
8 SEX
9 COLOR
Ui h / 7"~c
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) . b < h e**. </*> c*.
Due To
(b) .........
if.
(c)e l'l.3rn<y<i/ $
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis
? C.tl Vo « .*• f ,
S Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
... M. D.
(Address)
(Print or Type Name) / _ ,
,3rr. i%bC>.
Place of Burial or Cremation ^City or Town) ✓
Jr,
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTO
ADDRESS
Received anfci
A TRUE COPY ATTEST:
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
.MARRIED
WIDOWED
DIVORCED ,. ' .
UNKNOWN S/Vy/^,
HUSBAND of ..
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in full)
12
AGE
^ 1 ... Years.... $L.
-2 7
Months..** ?.. Days
If under 24 hours
Hours Minutes
13 Usual
Occupation f.
//- eq Jet /
(Kind of work done during most of working life)
or Business:
Social Security No...
BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
;c/4js
\7" <S AJ
18 BIRTHPLACE OF
FATHER (City)
(State or country)
S/.f/74/ #:///
4/ "#<//&// </
19 MAIDEN NAME
OF MOTHER
Se/y\
SYA~
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
21 Informant
(Address')
MAtf/Ste? 7, /////
fl rnAk Sr MrrrTZ/
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
C.c>±Jr.y..
(Signature of Agent of Bot ,
ifnation) (Date of Issue of Permit)
^XlAjtZCc-
Board of Health or other)
(Official Desii
■ I
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
o : •/
V-*n . Jj*'.
•■++• * •••••••• •%*.• i
18%,
• • v v* ‘ -
The fulfillment of the purpose of these laws calls for the observanM’dTJ tl*e PM
following rules of practice: -TlvtJU ' •«
(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.
DRM R-301
for burial permit
ard of Health
ts Agent.
{RUCTIONS
FOR
i CERTIFICATE
OR TYPE
OR CAUSES
DEATH
tot enter
than one
; for each
(b) and (c)
loes not mean
ie of dying,
heart /atiure,
etc. It means
sc, or compli-
which caused
iitions contrib- .
death but not
o the terminal
ondition given
fl.c ■
62-932382
Stye (Enmmflnumiltli nf UlafiHarljttartta
..Su.f.fal.k.
(County)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(ViN'IHROt
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
20
CERTIFICATE OF DEATH Registered No.
.v. Cliff House Nursing Home. 1.ZQ.
PHYSICIAN — IMPORTANT
2 FULL NAME..
John M. Nil and
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
) U. S. War Veteran
\if so s
Spe?.y wAi^.o.ani.sh...
(a) Residence. No 2. If. Lincoln of.
(Usual place of abode)
..St..
(If nonresident, give city or town and State)
Length of stay: In place of death years.. u ..months days. In place of residence.^.tOyears months days.
1
MEDICAL CERTIFICATE OF DEATH
3 death ,F. Ee.br.uany. S. 196.6
(Month) (T)ay) (Year)
4 I HEREBY CERTIFY^ That 1
19 to..../r*2Ur/). >3
I last saw fitful ive on
attended deceased (com
—a 19..^??....
...., lflj^^>leath is said to
have occurred on the date stated above, at
8 SEX
9 COLOR
Male
White
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Due
(b) £4^./.
JZC.
Due To
(c)
•K-- f*
OTHER , „ / /
SIGNIFICANT
CONDITIONS
t*-
INTERVAL
BETWEEN
ONSET AND
DEATH
12
AGE-90.. Years
Months
Days
Was autopsy performed?
What test confirmed diagnosis?
, M. D.
..Af/.Csr...
Dated^5^*...Si). 19.6
6 Winthrop Win t hr op Mas s
Place of Burial or Cremation (pity or Town)
February 8, 1966
DATE OF BURIAL
7 funeral director .Arthur J..«. 0 * Maley
address Winthrop , Mass.
egistrar)
personal and statistical particulars
10 SINGLE (write the word)
MARRIED, . . ..
widoweiW i dowed
DIVORCED
UNKNOWN
1 1 If married, w^i
HUSBAND
■d, widowed, or divorced, ,
0f ...Eli.^
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
If under 24 hours
Hours Minutes
13 occupat ion H ? t i p © d p i pc F i t t er
(Kind of work done during most working life)
or Business:.. II. S.. Naval. Shipyard
IS Social Security No..
16 BIRTHPLACE (City) BOStOU
(State or country)
17 NAME OF
father Thoraa
s Niland
18 BIRTHPLACE OF
FATHER (City)
(State or country)
....Westoort ('9
Tuf*1 nnd
19 MAIDEN NAME
of mother Mary McGuire
20 BIRTHPLACE OF
MOTHER (City)
....Ros.-ton
(State or country)
Mass
Gerald Niland
212 Lincoln St., Winthrop
21 Informant
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
w^s filed with me BEFORE the burial or transit permit was issued:
(_ V. , . (Signature df , Agent (if Board of Health j>r other)
(c. t?y.. -
(Official Designation) (Date of Issue of Permit) r
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE 5.t.L2.t.L8£8.
DATE OF DISCHARGE 1.t.15.t.18.9.9.
RANK, RATING Landsman
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice: •
(1) Attending physician* will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify tp all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
' ^ •' V >
<r/v
y/y.vnp nv
[Hi)?.
FFS~ 7/955 f/f
ORM R-301
for burial permit
>ard of Health
its Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
tot enter
than one
: for each
(b) and (c)
foej not mean
le of dying,
heart failure,
etc. It means
se, or compli- ^
which caused
ions, if any,
gave rise to
cause (a),
the under-
cause last.
litions contrib-
death but not '
o the terminal
ondition given
AC,
43-936348
(Hljp (Slammmmitttltlj nf
Suffolk
(County)
Winthrop
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHROP
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
.A ■*..
(CityorTown) LLKliriLAIt CM" LJC.M I M Registered No.
38 Harbor View Ave ((If death occurred in a hospital or institution,
No St. ( give its NAME instead of street and number)
°1
PHYSICIAN — IMPORTANT
2 FULL NAME..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
. / (Was
1 U. S.
t.if so t
Ellen F (Watson) Metcalf
”'as deceased a
War Veteran,
specify WAR)
38 Harbor View Ave.
(a) Permanent Residence. No St
(Usual place of abodj)^
Length of stay: In place of death years months days. In place of residence years months days.
(City or town and State)
3 DATE OF
DEATH
MEDIAL CERTIFICATE OF DEATH
..jZ.^rJj.
(Month)
(Day)
llAfi
(Year ) r
4 1 H E R
£BV
BY C E R T 1 F Yrr, That 1 attended deceased from
9s33?.., to ..../—Qjjr-'.. 7/.. , i9 ..(e.fe...
I last saw h^/.'STTve on i. yZ , 19. CU death is said to
have occurred on the date stated above, at
8 SEX
Fenale
9 COLOR
White
10 SINGLE .(write .the .word)
MARRiEDMarned
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
\Oq c^..^..c^..ce..^..<^...L.<^l
— /„■> 1
Due
(b )e«'^....^^^
y.
^7.///.^
SIGN^FICANT^...^
CONDITIONS / S
INTERVAL
BETWEEN
ONSET AND
DEATH
IP
Was autopsy performed ?
What test confirmed diagnosis?
way related to occupation of deceased?
// "J"
Mayflower
Place of Burial or Cremation
DATE OF BURIAL
Feb. 9
uxbury
(City or Town)
66
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Howard S Reynolds
Winthroo Mass.
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(Give maiden name of wife in full)
(or) wife of T.heodpre..IIetcalf
(Husband’s naSne in full)
12
AGE
:93 a
0 7
ears Months 1 Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
Housewife
(Kind of work done during most of working life)
Own Hone
14 Industry
or Business.
15 Social Security No
16 BIRTHPLACE (City). iVTIlCUt tl
(State or country)
Mass
17 NAME OF
FATHER
Albert Watson
18 BIRTHPLACE OF , ,
FATHER (City)
(Stat? or country) Mass
19 MAIDEN NAME
OF MOTHER
Augusta Man ter
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Mass.
21 Informant
(Address)
John Metcalf
33 Harbor View Ave. Winthrop
1
I HEREBY CERTIFY- that a satisfactory standard certificate of death
transit permit was issued:
A TRUE COPY ATTEST:
* .... ;rTG!v-
0)^77- - :
. . i ( L i ' c
^ %/£ ■ V; .
.< •
SPACE FOR ADDITIONAL INFORMATION
•vj <1ti ll* • .
DATE OF ENTERING MILITARY SERVICE.^:'
DATE OF DISCHARGE F£B.“ C.IS3.G M.
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.
ORM R-301
I for burial permit
sard of Health
i its Agent.
I AUCTIONS
FOR
I. CERTIFICATE
I" OR TYPE
OR CAUSES
DEATH
not enter
; than one
e for each
i, (b) and (c)
does not mean
de of dying,
heart failure,
etc. It means
ise, or compli-
which caused
\itms, if any,
gave rise to
cause (a),
: the under-
cause last.
ditions contrib-
death but not '
to the terminal
condition given
63-936348
A
(County)
Winthrop
(City or Town)
Bay View Nursing Home Sturgis
QItjp (Enmmmuiipaltfj of fHanHadjuaptlH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
ttlNTHROR
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
oo
../Srf.Ssrf...
No..
f (If death occurred in a hospital or institution,
..St. j give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME. Kat> her J (Gonnley) Jackson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Permanent Residence. No. ....?.7.....£l.9®.?®.nij St.
(Usual place of abode)
5 5
Length of stay: In place of death,..r!....years months days. In place of residence years months days.
J (Was deceased a ..
) U. S. War Veteran, NO
(if so specify WARi
Winthrop
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
"(Month)
<DS?>
4 J Ji F. R E I! Y CERTIFY, That 1 attended deceased » front
Met.. /.* v l o , ,0 fc ,9 Lh
I last saw h.fcULlive on C. /S 19 4hC>, death u said to
have occurred on the date stated above, at & m. I INTERVAL
BETWEEN
ONSET ANO
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) *PfJtu*niA/> A —
Due To
(b)
~J> /s s- ft-nT
— & — *r ‘ s rune
Gr'e*/*utL a* rm/t) 6 //v'
Due To
(c) _ - - ---- -
OTHER W't-f/ywwji
SIGNIFICANT '
CONDITIONS
Ajsw e —
-$L
12 Co
If under 24 hours
' AGE OO. Years
Months
Days
Hours Minutes
Was autopsy performed ? A e -•••••• — * 2
What test confirmed diagnosis? . L / CSt ( —
5 Was disease or injury in any way related to occupation of deceasei
If so, specify
(Signature)
~E
/iiyfcSaiMIZ 'M. ML.
(Address)
6 New ...Calvary Boston
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Feb. 11 19.66.
funeral director -aurice W Kirby
ADDRESS
WJnthrpp
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
married Widowed
WIDOWED IUUWOU
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of.. Edward. H Jackson
(Husband’s name in full)
13 Usual
Occupation .
14 Industry
or Business.
Home Maker
(Kind of work done during most of working life)
Home
15 Social Security No..
16 BIRTHPLACE (City).
(State or country)
None
Boston;-
SS^.
17 NAME OF
FATHER
Henry Gormley
18 BIRTHPLACE OF
FATHER (City)
(State or country)
N.B.
19 MAIDEN NAME
of mother Gather in* Burges a
20 BIRTHPLACE OF
MOTHER (City)..
(State or country)
Ireland
21 Informant ..Edward.fi Jackson Jr,
(Address) 3.7 ...PI easant St. w' inthrop,Masg
s
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agenl of BoartLbf Health or other)
i,)7 7 X
(Official Designation) (Date of
(Date of Issue of Permit)/
A TRUE COPY ATTESTr
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE ,
DATE OF DISCHARGE
- ■ ■ - •- — - '
RANK, RATING iw...,.;,...'...
-v'
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for tlle£fiservS<iG<i{ 1
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
for burial permit
ard of Health
ts Agent.
t RUCTIONS
FOR
1 CERTIFICATE
i OR TYPE
I OR CAUSES
IDEATH
not enter
i than one
: for each
(b) and (c)
'oes not mean
lie of dying,
i heart failure,
etc. ft means
ise, or compli-
which caused
ions, if any, )
gave rise to I
cause (a), >
i Ike under- l
: cause last. )
litions contrib- .
death but not
0 the terminal
ondition given
62-932382
OInmmnnuiFaltli nf fHaaflarf|U0?tt0
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
iw
]Q (County)
/(a
)° I.int.h.r..Q.p.
|u *r
.Ho.us.fi. J5ur.sl.ng; Home st. PS™ *«*? namT^
STANDARD
CERTIFICATE OF DEATH
Registered No.
\0h Wo..S/.?#r..*..4r.A lls/«U4.Vw;. bt. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME J(Was deceased a
(If deceased is a married, w i do wed^or divorced woman, givealso maiden name.)
XUl ‘
(a) Residence. No .iflvl..!...
(Usual place of abode) / ^
Length of stay: In place of death....6..years months days. In place of residenc<ttfy.years..
/(V
| U. S. War Veteran, T\Tr\
Uf so specify WAR) slj.Sn..?.
.CIi.i.Qr!igQ.f
(If nonresident, give city or town and State)
..months days.
...W.int.hr.o..p.
(City or Town making this return)
f)Q
Art.O
MEDICAL CERTIFICATE OF DEATH
3 DATE OF 1 C p.
DEATH L...E.1... *
(Month)
..£
(Day)
1ST
(Year)
4 (HEREBY CERTIFY
Ta.vv , vj;r
......... . , That I attended deceased from
JQL., to. />.£. £, .9 .1.1...
I last saw h.»«^live on ... j£d£..)0....r J. 19...4..” death is said to
have occurred on the date stated above, at ./cy./Xi
8 SEX
9 COLOR
mala
colored
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
a) Q zxe hi a
Due
(b) .
! & f y ,f..b x?/. Ax.i^.y 5 'ijts
Due To
(c)
H
£
py
-feitSr
ci*i
Sffi.CANT kts/lAl,
Condi Hons JK.>y ypusle
f
INTERVAL
BETWEEN
ONSET AND
DEATH
%
/Clj
YS,
W'as autopsy performed? ...
What test confirmed diagnosis? .&4X.V L..1.0...X+......
% y>-s
S Was disease or injury in any way related to occupation of deceas ed^/£.
If so, specify ...........
(Signature) [l^.t^..X'ir^L..^..y..:.l T. . . , M. D.
£ti..d..&.L..£..S. L.L.0..fT.j3..^..^A.'....
(Print or Type Name) . .
(Address) U ...U\...L./i:..l\6^ 19„.fe..(r..
6 ...
Place
.W±n.thr..Q.p G.ejne..t.er.y.^..Vifiiithr.o.p.,. .Mas
*lace of Burial or Cremation (City or Town)
date of burial ...Ze.br:iLa.r;y: 14..».1.9..6.6 19
7 FUNERAL DIRECTOR HlXe.! B..n MaX.St.h
address I.7.4. .W.in.t.hr..o.p S..t.«. .W.int.hx.o..p.,».
Received and filed L 4 19.
ar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRiEDWl flowed
WIDOWED
DIVORCED
UNKNOWN
husband of .Yl.b.l.a....Eendri.c.k.s
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGl8J — Years 9. ...Months 2 Days
If under 24 hours
Hours Minutes
Occupation:... Rigger
(Kind of work done during most working life)
14 Industry
or Business:
,U, S . Army ...Grdrignc e
Social Security No 2.58.r" IQ *~26.19.
BIRTHPLACE (City).
(State or country)
Manama
17 NAME OF
father Jacob Shearer
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
Jarusal em
19 MAIDEN NAME
OF MOTHER
T d a. ? |
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Jerusalem
1 Informant .M.r.S..*.
(Address)
.....Rax...£xe.e.n !
261
Shirlev St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
Ma»® ^led with me BEFORE the burial or transit permit was issued:
d- fgj
' , (Signature of Agem$t Bo«m of. Health or other) , ,
(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.
^8141956 Frt
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
I for burial permhT
l*rd of Health ^
Its Agent. Cj
$
RUCTIONS
FOR
CERTIFICATE
Nr
OR TYPE
DR CAUSES
DEATH
lot enter
than one t^-
: for each SL
(b) and (c) V
'oei not mean
ie of dying,
heart failure,
N4
IL
etc. It means Q
lire, or compli-
O, l/f rrt fruo- .
ohich caused
ions, if any,
1 gave rise to
cause (a),
the under-
! cause last.
iitions contrib-
death but not *
o the terminal
ondition given
Ns
<1
62-932382
(Enmmnmuralfy nf
K
H
Iw
S.uf.f..Q.l.k..
(County)
I
w.i.n.fchr.Q.p....
(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.
_ ((If death occurred in a hospital or institution.
No Wi-Jl-tfiP-O-p ShOPft DPi VC St. ( give its NAME instead of street and number)
2 FULL NAME..
Gerald C. Grimes
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
j (W
1u.
(.if s
as deceased a
S. War
so specify
Wii«i w w~y.
(a) Residence. No : 250.VfJLn.fchr.QP. ShorjR Drive st.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.*^...years months days. In place of residence. years months days.
MEDICAL CERTIFICATE OF DEATH
DEATH * Ee.bru.arv 1.2., 19.6.6...
(Month) (Day) (Year)
4 I HEREBY CERTIFY
19 to
I last saw h alive on
That I attended deceased from
19
19 death is said to
have occurred on the date stated above, at .. *L‘/ o...fc. ..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
...TNc u 4Jj uiu j 6 /..l
" 1 " "7 , 4774 1 /
Due Topf u <? 4() W<T( f U.Y d( /
(b)
Due To £ Cl F-S <
(C> "IT
OTHER - - r\ a \
SIGNIFICANT
CONDITIONS I* U A 1 U-
INTERVAL
BETWEEN
ONSET AND
DEATH
rS'
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased Vf/fy
If so, specify ...Ch
(LLl^£u?.. . NN bu
(Signature)
LV.< , M. D.
er.aan...
..Ghar.lft.s
, (Print or Type Name) _ / / , ,
(Address) L^..I../.LL.lt&(?..l'.,...^
y.AL±h.P.P.d. T3 rocket Nt=.
f Burial or Cremation (City or Town)
£ £.£> l£1
Place of Burial or Cremation
DATE OF BURIAL
7 funeral DiRECToiAp..t.hur J... .Q...!..M.ale.y...
address W.inthrop.j M.a,S..S.
istrar)
A TRUE COPY ATTEST
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Mai ft W|
9 COLOR
hi tft
10 SINGLE (write the word)
MARRIED
WIDOWED —pi ' /
DIVORCED \>t v CKct/
UNKNOWN
11 If married
HUSBAND
■d, WuJlSWed, nr. divnrreH • ■
of 4)..h^.p:±<L
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
AGE1** h.Years Months Par’s
If under 24 hours
Hours Minutes
U Occupation: §31*™™
(Kind of work done during most working life)
14 Industry 0 _ I _ ^ . _ ,
or Business:
15 Social Security No „
16 BIRTHPLACE (City)
(State or country)
MA
17 NAME OF
FATHER
Mi char;] J. Grimas
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF mother peija Conncllcv
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Ireland
21 Informant
(Address)
Sri/-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
..£.a^i
. (Signature of Agent of Board pf
~ . (Signature of Agent of Board pf Health or other)
(Official Designation) (Date of Issue of Permit)
(Official Designation)
(Date i
Permit)
c.n, firl
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE ...Qc
DATE OF DISCHARGE
F.e.b..l8.r... 19-4.8.
RANK, RATING .1.
ORGANIZATION AND OUTFIT ILJS...N.JL.
SERVICE NUMBER .?.9.9. 7.7 .?.... ‘
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the FTQ "J 'IpCC CV
following rules of practice: 1 L Lf _L ^ I O 0 0 'fl
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook-
hotel, etc. For a person who had no occupation whatever write none.
>RM R-301
I
or burial permit1-1
trd of Health Jv
a Agent.
UCTIONS
:0R To
CERTIFICATE
OR TYPE
R CAUSES
)EATH
ot enter
than one
for each
(b) and (c)
>es not mean
it of dying,
heart failure,
etc. It means
e, or compli-
'ihich caused j
N
u
ms, if any,
•ave rise to
cause (a),
the under-
cause last.
it ions contrib- ^ «.
death but not
the terminal
>ndition given
Q.
\.c
2-932382
©Ij? (Enmttumuiraltlf of HUaHHarljuaettfi
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
or.
Suffolk
(County)
Winthrop
(City or Town)
? / -n-t )Ui aeatn occurrea in a nospital or institution,
No ^}t). SSUlU t St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME ^..93.^A £• Mi.P.P. I (Was deceased a
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH Registered No
f (If death occurred in a hospital or institution,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 5.6. P.l.e.&s.&n.t. 5..t..«..., st..
(Usual place of abode)
.. ) (Was decea
3 U. S. War \
(.if so specify
Veteran,
WAR)..
(If nonresident, give city or town and State)
Length of stay: In place of death.B. years months days. In place of residence... 8...years months days.
MEDICAL CERTIFICATE OF DEATH
DEAT hof Fe he war y 13.., 19.6.6...
(Month) jfuay) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
19 , to 19.
I last saw h alive on 19 , death is said to
have occurred on the date stated above, at ....
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) I^..&..a.b..L p.r.fT..t.“i..g...bi.|f.
llrAli* £.A.L.S<?S l...
INTERVAL
BETWEEN
ONSET AND
DEATH
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
— zX, -
5 Was disease or injury in any way related to occupation of deceased/?
If so, specify /). ../f.l......
(Signature)
„ (Print or Type Name)
(Address) L'l'!/.Z.V...7T/A..(2.l3)..T/.'Ci.J.Date....T././.^;/..19
Sjf M. D.
6 St. Agnes Greenport . N . Y .
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .RcbrUarV 17 19...66
7 FUNERAL DIRECTOR thUP .Q..!...M3lCY
Winthrop, Mass.
ADDRESS
Received and filed
8 SEX
9 COLOR
Male
Whi te
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED _ .
widowed Single
DIVORCED °
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
AGE 6 2 Years
Months Days
If under 24 hours
Hours Minutes
13 Damnation :^«.tired. Pharmacist
I Kind of work done during most working life)
or Business:.. Drug Store
15 Social Security No.... 572-13-35.57..
16 BIRTHPLACE (City) Br.O.O.kl.y^r^.4.v. ..
(State or country) ivi*»TAr
New York
17 NAME OF
FATHER
John W. KliDp
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Germany
19 MAIDEN NAME
OF mother Catherine
Sc ha urn bur g
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
New York
21 Informant .. Arnel.i.a....Melan.s.on
(Address Pleasant St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
o
s filfd witl
A (Signature of Agenf df Boar# of Health or other) / /
■JWtL fJjl/L L
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.
FEB 141966 Fil
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 oyer. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
ORM R-301
for burial permit
ard of Health
ts Agent.
RUCTIONS
FOR
CERTIFICATE
OR TYPE
OR CAUSES
DEATH
tot enter
than one
for each
(b) and (c)
'oes not mean
le of dying,
heart latlure,
etc. It means
se, or compli- ^
which caused
ons, ij any,
lave rise to
cause (a),
the under-
cause last.
litions contrib- .
death but not
3 the terminal
ondition liven
tit
A'
cpV
\y
=3-936314.8
N?7/)
3 4 f - f at- K
^ikunVy) y,r^
®1jp (Eammmtuifaltfj nf HHaaaar^UHPllH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
on
f Ijl). _
/H (C'\t\T rtr Tnutn\ CERTIFICATE OF DEATH Registered No.
—L-), 1C /— A C J n!/ / /- ((If. death Occurred in a hospital or institution,
/. [e'..£\£*..../L/. (a ^.i./jpTKXSt. | give its NAME instead of street and number)
1/1 / PHYSICIAN — IMPORTANT
FULL NAME J r~ L I . Le J^ .i .O / (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) j U. S. War Veteran, —
V if so specify WAR) /M).
S.jDl.i*).y*L*' /s-ea, A1a ss.
(a) Permanent Residence. No.
(Usual place of abode)
Length of stay: In place of death 7... years months days. In place of resldenceȣ(i/.years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF CTc- Q
DEATH H...h~... Q
(Month)
.1.3.
(Day)
mt
(Year)
HEREBY C lyR T I F Y That I attended deceased frmn
19,....fo.^^p. 19...<LL.
I last saw h /alive on / / ArCR.. , 19 death is said t"
have occurred on the date stated above, at . . m. INTERVAL
BETWEEN
ONSET AND
DEATH
}}UAvu3o
8 SEX
9 COLOR
C.PUJ
DEATH WAS CAUSED BY: IMMEDIATE CA
)
DEA
(a
CAUSE
1 )ue
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? Mo.
What test confirmed diagnosis?
n r /
If under 24 hours
AGE y 6 Years
.... Months
Days
Hours Minutes
/6y,+
5 Was disease or injury in any way related to occupation of deceased
If so, specify
ADDRESS ^ y...../ZL£L.£..7.
7 NAME OF
FUNERAL DIRECTOR
UJ.S.6
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED , , . . _
UNKNOWN CJ I DC (l) c- Q
HUSBAND of .
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in full)
13 Usual
Occupation.
L.S..S.o..7^.£..f3.
(Kind of work done during most of working life)
14 Industry
or Business.
15 Social Security No. G / tb. (o '. 7
16 BIRTHPLACE (City) 7U J) .2/ ,? q.
(State or country) ' VI—
17 NAME OF
FATHER
U A~ uu aJ
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
19 MAIDEN NAME
OF MOTHER
MAR..j-£S
/ m l j
6O1 1'd'hoi^y^
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
.J/AEl£S..
/mi./
21 Informant
/McM±$s O/ G> U.L/..&.
(Address) yf...(o. F..B.LMjI/L S..£ QM/EjLSAB...
I HEREBY CERTIFY that a satisfactory standard certificate of death
filed ^ ith BEFQRE the^burial or transit permit was issued:
Ageuy of /Board of Health or other)
(Date of Issue of Permit)
A TRUE COPY ATTEST:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and bv 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.
//Xy ■
/a,
6
F£G 1 '21966 Ffl
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 <jf 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.
!
100M-5-6U-938000
ulljf (Hmmnmtuiraltlj nf iUaflHarl|UHftt0
1 §
Norfolk
(County)
Braintree
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Braintree
(City or Town making this return)
No..
COPY OF
CERTIFICATE OF DEATH
Monatiauot Nursing Home
Registered No.
22
((If death occurred in a hospital or institution,
St. | give its NAME instead of street and number)
2 FULL NAME Thomas. A# Jones
(If deceased is a married, widowed or divorced woman, give also maiden name.)
( (Was
< U. S.
( if so
as deceased a
War Veteran,
specify WAR)..
No
(a) Permanent Residence. No 9 Crystal Cove Ave.
St..
Winthrppj, Mass,
(City or town and State)
Length of stay: In place of death years months...^., days. In place of residenceTj^.years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Feb.
(Month)
(Da>0
1966
(Year)
4 I HEREBY CERTIFY, That 1 attended deceased from
Feb. 9 w-66 , to Feb. 14 w 66
I last saw hiniive on Feb* 13 >‘'66, death is said to
have occurred on the date stated above, at ..8 j l5 A m-
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
Male
White
WIDOWED
DIVORCED
UNKNOWN
Widowed
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due
(b)
General
sc-Ierosi:
e To .
Cerebral Arterio-
£ ev.yrs
Due To
(c)
Arteriosclerotic
Disease
Heart
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
^ev. yr i
Was autopsy performed?
What test confirmed diagnosis?
No
Clinical
5 Was disease or injury in any way related to occupation of deceased? No
If so, specify
(Signature)
M. Pearlstein
M. D.
Pearlstein
(Address5Q6 Wasb.St. #Bra. DatJPeb. 15 .1966
6 Forest Hill Crematory
Place of Burial or Cremation
DATE OF BURIAL
Feb. 17*
Boston, Mass.
(City or Town)
1. 19.00..
7 NAME OF
FUNERAL DIRECTOR
Robson Funeral Home
ADDRESS 4o Sea St. # No. Weypjouth, Hass,
Received and fil
FEB 1T1966
PERSONAL AND STATISTICAL PARTICULARS
II If married, widowed, or divorced
husband of Mary A. Bennett .
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE 83 YearvlQ .Months. 10 Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : PrfiSSIOajl
(Kind of work
done during most of working life)
14 Industry
or Business:
Boston Post
IS Social Security No.
16 BIRTHPLACE (City).
(State or country)
■Q25-Q5-6742A
17 NAME OF
FATHER
ISS
Elias Jones
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Ireland
Helen Kemp
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Scotland
21 Informant
Mrs. Florence Mazza
(Address) .28 Aspinwall Ave., No. Weymouth,
— ■ Mass*'
A TRUE COPY
ATTEST
DATE FILED
& h •
/ (Registrar of*CIty,,*To»n where death occurred) Ks
T f D ■ ^ lwvw m
19..
0.0. I t, /
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
D
1 71956 to
tM R-301
burial permit
| of Health
Lgent.
'.RTIFICATE
1 TYPE
CAUSES
ATH
enter
an one
ir each
i) and (c)
$
*
I
b
not mean
I of dying,
itsrt failure,
. It means
or compli- .
ch caused
, H any, J
e rise to I
ase (a), )
e under- I
ite last. 1
\>ns contrib-
uth but not '
he terminal
>ition given
Qtyr (ftnmmmuuealtly nf iKaBaar^uaptlH
-•j
5)39763
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHROP
Suffolk
(County)
W I NTHROP
(City or Town)
No .W..1..N..T..H.R.Q.E H.Q.S.P 1IA.U s..{(8“
J . PHYSICIAN — IMPORTANT
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
Registered No. 28-
Will 1 am l Brown (
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
iif so specify WAR)
2 1 Pleasant St.
(a) Permanent Residence. No St..
No
Winthrop Mass
(City or town and State)
Length of stay: In place of death years months....!... days. In place of residence A-.^tyears months days.
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
7T
(Month)
(Day)
m £
(Year)
4 I HEREBY CERTIFY, That I attendee-deceased. fr<
19 to JEEB /J
I last saw h//t|live on t d / S ^ ^ ^ 19 ^ ©death is said to
have occurred on the date stated above, at ...
ir'/.ra.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
. . . /}? v TS C U M. */' ffUr. Y Qcc u*/ » »
Due
(b)
I”. ftKP&u • SCi*ju>7 re
Due To
(c)
OTHER . /
SIGNIFICANT A/ i)yidL*rr
CONDITIONS '
7^
INTERVAL
BETWEEN
ONSET AND
DEATH
C
8 SEX
Hale
9 COLOR
White
10 SINGLE (write the word)
.MARRIED
widowed Harried
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of Hcl.en....G.*.
....Gur..fcin
/y
yiej-
Was autopsy performed? /.V...SI ^
5? ^/-//V/cyru
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ^
If so, specify ..
(Signature) ...
M. D.
(Address)
6 Winthroo Winthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL E.£.hr..U.&T.,Y. 1.8. 19.'
7 NAME OF . 1 , T r\ 1 t -1
FUNERAL DIRECTOR An.tllUP. .J..* Q..!..liia.l.e.y...
a ddr ess W.i.n..thr.a.Pp..,....Na.s.i
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in full)
AG
l6 6... Y
ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation . ..Retired MGh.in.ts.t
(Kind of work done during most of working life)
14 Industry
or Business:.
.General, Electric Go..
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
030- 01.- 54.7
rn.iia
Pennsylvania
17 NAME OF
FATHER
Alfred Brown
18 BIRTHPLACE OF
FATHER (City)
(State or country)
..P.h.l.l..adel.phi..a.
Pennsv lvania
19 MAIDEN NAME
OF MOTHER
Louise Crook
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
.Philadelphia...
Pennsylvania.
21 Informant Helen...G.. Brown
21 PI easant St., Winthrop
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
vas filed__wfth nunBEFORE the burial or transit permit was issued:
(sigh
^ . (Signature of ^gen( of Board of Health or other) j
.). Jrr.fAryA. /.L2/..(?.A..„
(OfiWiad 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.
J
FfB 1 71956 M
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
l/:
X
\< SUFFOLK
]Q (County)
/
AO
iw
fU
<
\ J
\CL
WIKTKROr'
(City or Town)
No..
$l|p GImnmmiuiraltfj nf IHaBaarljUfiPttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHROP
(City or Town making this return)
2!)
2 FULL NAME
PAUL 0 GAFFNEY
STANDARD
CERTIFICATE OF DEATH Registered No
p< jv- ((If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
16 THOiftON PARK.
(a) Permanent Residence. No St.
.. ) (Was deceased a Tr , T _ _
) U. S. War Veteran, W . W . H
V i f so spec''
18 18
Length of stay: In place of death.-.^.^years months days. In place of residence TUTyears months days.
specify WAR)..
(City or town and State)
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
Feb lb
(Month)
(Day)
19.66
(Year)
4 I HEREBY CERTIFY, That I attended deceased (rom
19 to... / ^C. 19.
I: last saw h..J.t*Ji
ed Ir<
,d
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
Male
White
divorced Mo r*-r1 prl
UNKNOWN iiai- A x e u
- I.utjive on i.KT 19.i£.i? death is said
have occurred on the date stated above, at %JL A Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ..£-&XC UJhCM (£L<2...6..J.U£j
Due
(b) .
7
Due To
(c)
^..D..^..c.k
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? . -i&e.
What test confirmed diagnosis?
INTERVAL
BETWEEN
ONSET AND
DEATH
/ hr.
J'W YS
5 Was disease or injury in any way related to occupation of deceased?
~
(Signature) yU)...«dL M. D.
.d.ti.A-.(3..L.Q.S
(Address)
(Print or Type Name) / j -
6 Winthrop Wlnthrop.. .
tn)
Place of Burial or Cremation
DATE OF BURIAL
Feb, 17
(City or Town)
,66
7 NAME OF
FUNERAL DIRECTOR Emest P GaggiaHO
ADDRESS
147 Vi in thr o p St. Wlnthrop
Received and filed
A TRUE COPY ATTEST,
:egistrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed,
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
AG E !?. ^ . . Years. . .
? Months . 5 Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
nealth Aggent
(Kind of work done during most of working life)
14 Industry
or Business:.
Town Of Wlnthrop
IS Social Security
No
1<S BIRTH PI.ACF
( Citv)
bonbon
(State or country)
Mass
17 NAME OF
FATHER
Peter Gaffney
CO
H
18 BIRTHPLACE OF
FATHER fCitv)
Chelsea
z
(State or
country)
Mass
CC
<
19 MAIDEN NAME
OF MOTHER
Sarah Marshall
0M
20 BIRTHPLACE OF
MOTHER <C itvl
Last Boston
(State or
country)
Mass
F
71 Informant P 1 QPif flTPV
(Addre.si .16 Tho.33tffc.Qn Park*. Wlnthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
wgs filed .with i ltd BEFORE the burial or transit permit was issued:
A (Signature of ^gent of Board of Health or other)
(Official Designation) (Date of Issue of Permit)
t/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE 5/^.3.
DATE OF DISCHARGE
RANK, RATING .P.?.*Y.^..e
ORGANIZATION AND OUTFIT Army 2A2nd...AAE*...Basa..IIlli.t
SERVICE NUMBER 3.1. .422.. 3.41
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physician* will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
FEB 1 719!
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.
/
®Ijr fflummanuiraltlj nf IRapsarbuiiFttB
i nm
Q (County)
(^rvt
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
VYINTHROP
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
30
llJinth.su> o
I W (City or Town) CERTIFICATE OF DEATH Reg.stered No.
I j . MntiJ-J nmo/r „ (Of death occurred in a hospital or institution,
\Cu No St. j give Its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME ‘ C
(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) Permanent Residence. No. ...l.I.8....P.SMt(lA)l^gtt).t!%....St.. C.G.d.t:...!. 04'trQYltii.
Length of stay: In place of death. ..^.... years months days. In place of residence'^^years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF CL,/.
DEATH
(Month)
19......
(Day)
1.9.66
(Year)
attended deceased from
4 IHEREBY CERTIFY, That I
19...la(» to I..9.
I last saw hAC.alive on ...... 19 death is said to
Uli o
^T7...j3...m.
AUSE
8 SEX
CeMite
9 COLOR
(ihite.
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
vlido wed
11 If married, widowed, or divorced
HUSBAND of
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAT
£(y£M.y*..ff.. r>..iM
Due Selene j- ,c Un.rte.i- Q ..
"r iLjD.x.-gi.eijcfc...
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
fcl njs
12
73
If under 24 hours
AGE
\ ears
.... Months
Days
Hours Minutes
jo
Was autopsy performed?
What test confirmed diagnosis:
7FF
5 Was disease or injury in any way related to occupation of deceased?*.?.#
If so, specify
*2?.'.'^:. m. d.
P?.A
(Print or Type Name)
(Address) A.hr. \9.£.(c..
6 kjaJUf....C^o.44 Naldm
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
9eb<tisMytij 22 w 66
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
flytfhonif P. Papisio
9 ChelA&a St. [cu\t Norton
A TRUE COPY ATTEST:
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(or) WIFE of..
(Give maiden aiame sf wife in
i/aetano utbix* o
in full)
(Husband’s name in full)
U Occupation C&dlj JA.P^.
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
Petlyr.&cl
0I2-I8-~ZJW
16 BIRTHPLACE (City)
(Stale or* country)
17 NAME OF
FATHER
'tioMSUic Crtpi.-7.-pi
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ptcdbf
19 MAIDEN NAME
OF MOTHER
tyo'ip.phiyie rin.pa.Ldt
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
ptatif
21 Informant
(Addre
p^oce. pPAAnl ( daugkteA.)
..■J IR ^ennirtc.tott *>t. f [cuit &04 ton
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filedi^th me^BEFORE the burial or transit permit was issued:
(Official Desi
Designation)
Ager\t of Bedard of H^lth or other) / /
(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 FRACTICE
'Hi
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 psrthpsg of-pftso/VS
to whom they have given bedside care during a last illnesf (r<jyi 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.
Afl
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.
Suffolk
(County)
<Li}t QJmnmflnmealtfj nf fHasaarljuBfttH
KEVIN H. WHITE VAIlWIUDHP
Secretary of the Commonwealth W 111 I n nUi
DIVISION OF VITAL STATISTICS (City or Town making this return)
STANDARD
CERTIFICATE OF DEATH R^' stered No t I ^
(If death occurred in a hospital or institution,
o winthrop %
U (City or Town)
j , Dqit \TA ou VI rr U rsri rs „ 1(11 death occurred in a hospital or institution,
2* No y.r..6.W.....i.l.Ur.Smg — GUI© St. f give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Isx.a.e.l....My.er Mlllmel.s.t.e.r. / (Was deceased a
~ ’ ’ ' ’ ‘ ’ ' AU. S.
\if so
(If deceased iaa married, widowed or divorced woman, give also maiden name.)
War Veteran,
specify WAR) XLO •
ed i& a
2$ Sturgis Winthrop
(a) Residence. No St
(Usual place of abode) (City or town and State)
Length of stay: In place of death years..9-.-.months days. In place of residence years.. „§L months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
if
(Day^ (Year)
I HEREBY CERTIF Y . That I attended deceased from
r< ■ 19 ^ f y ,
I last saw hl^live on p.CT'Jj*. \ \f , I'lfoc. death is said to
have occurred on the date stated above, at MiSC
Ay.
8 SEX
9 COLOR
male
white
(a)
DEATJI WAS CAUSED BY: IMMEDIATE CAUSE
LAMt^MA P&ffATE
INTERVAL
BETWEEN
ONSET AND
DEATH
.1 y>/4
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
widowed widowed
DIVORCED rtiUUWCU
UNKNOWN
11 If married, widowed, or divorced
husband of J enni e ,.W.Olf..;
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
86 .
AGE \ ears Months Days
If under 24 hours
Hours Minutes
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT,
CONDITIONS
NT/4 ^ *1CC Jkut.
'iffoi e
■?yar.
Was autopsy performed? (H?/, T / t
What test confirmed diagnosis I I J <3S- ( iH8:..0...t...
5 Was disease or injury in any way related to occupation o/ldeceased
If so, specif
&
..?. , M..D.
(Signature) I ft * . j...^
6 M.os..e.s Mendelsohn Hest Roxburv
Place of Burial or Cremation (City or Town ) d
,o 66
DATE OF BURIAL
Feb. 21,
7 NAME OF
FUNERAL DIRECTOR
Received and filed
Paul R. Levine
Bro
fWKTrm
Harvard St. , Brookline
Occupation ... Retired
(Kind of work done during most of working life)
14 Industrv . , ,
or Business Printer
15 Social Security No..
16 BIRTHPLACE (City) Rl.}.qq.Lp
(Slate or country) AUbSiB
17 NAME OF
father Barnet Millmeister
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
(unknown)
20 BIRTHPLACE OF
MOTHER (City)..
(State or country)
Russia
21 Informant M.X* . Louis .Hills on
59 Sumner Rd. Brookline
(Address)
I HEREBY, CERTIFY that a satisfactory standard certificate of death
.wgs filed wf)th me. BEFORE the burial or transit permit was issued:
G
r\ . (Sighatipe of Agent of/Board pf Hi
(Official Designation) (Date of Issue of Permit)
iealth or i
A TRUE COPY ATTEST’
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
6
The fulfillment of the purpose of these laws calls for the observance of the r- r- n
following rules of practice: r f f] O [OCp iu
(1) Attending physicians will certify to such deaths only as those of persons ** u A/ Ij'JQ hi)
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form pf
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiner* 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.
Suffolk
(Hljp (Eommnnuintltii nf IfllajaaarfjujaFttB
(County)
V inthrop
(City or Town)
no. Cliff House Mjx.sl.ng Home
k) c
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHROP
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
QO
5 (If death occurred in a hospital or institution,
..St. | give its NAME instead of street and number)
2 FULL NAME..! I L.M.Ay
(If deceased is a ma.
r
YSICIAN — IMPORT
(Was deceased a
J U. S. War Veteran,
V if so specify WAR)..
l\lo
PHYSICIAN — IMPORTANT
■^L-. L.LL'6. X^JOJL.
lajfried, widowed or divorced woman, give also maiden nftme.)
ry I . (j inn) I orrissey
(a) Residence. No St
(Usual place of abode^ Villi tin $Ve V - .
Length of stay: In place of death. ..Q. years months..... days. In place of residence.jjy.years months days
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
DEATH*1!.... /S
(Month) (Day) (Year)
4W HEREBY C E^R T IF), That 1 attended deceased from
to. /' Vi 6> £>
^last saw h.<L.faTive on /...Jr* .... vy£t(?. death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(aC-!^ -Jc-C*- i *1 M../h3rZ)..C2..T~.C>£../.....!$.
b)e tJh
I )ue T(/^
(b) Le. A /.C..y...2rT..«.af^^......<?.
Due To
(c)
SIGNIFICANT
CONDITIONS
g /?
Was autopsy performed?
What test confirmed diagnosis?
1
INTERVAL
BETWEEN
ONSET AND
DEATH
5 Was disease or injury in any way related to occupation of deceasep
If so, spe£ift
(Signature )\d?. .... GW "7 hi. D.
@ k:(/L...sa.c?./r/
y .// (friht or T^pe Name)
(A\
1 «I£.
6 .Jj.i|?ij^a„.lL€X^.....C..cn£.te^ Jjeahoriy
Place of Burial or Cremation
(City or Town)
February
DATE OF BURIAL u.*w...>..
.£6....
7 NAME OF i I >• , *r it*
FUNERAL DIRECTOR v..e
address A nfcfe.-g.iie. ~*.e.Y£.r..e..» 1.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED • j ,
DIVORCED lU O'i ed
UNKNOWN
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of..,,:homas...I,orrlss.ey
(Husband’s name in full)
12
AGE. Air ears IC^Ion ths.frr.^: . Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : -.iQU.S.QYv.if .G
(Kind of work done during most working life)
14 Industry
Business t .. . .Jl.QfflG. .
15 Social Security No
16 BIRTHPLACE (City).._._
(Stale or country) JeV fOUIlC 1c iT!
17 NAME OF
FATHER
John Finn
18 BIRTHPLACE OF
FATHER (City)
(State or country) Nev:f ounclland
19 MAIDEN NAME
OF MOTHER JlljBn It-.
Fob in
20 BIRTHPLACE OF . T
MOTHER (City)....hGVi.I.QUnQJr.allC...
(State or country)
21 informant ..Ethel Fairfield
(Address) gg v'hi tin Lve, Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with ine BEFORJ£?the burial or transit permit was issued:
(Signature of Agept of Board of Health or other)
: . . . /w .^Fr. . . .
(Offichy 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 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.
F£B 2:_
'i (s
MEDICAL CERTIFICATE OF DEATH
3 .1v£I!hof February
21
1 966
(Month)
(Day)
(Year)
®I|p (Crnmnnmupaltlj nf fHaBHadjuartlH
2 S.UFF..Q.L.K..
(County)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WlNTHROP
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
W I NTHROP
(City'orTown) CERTIFICATE OF DEATH Registered No U
V/ I NTHF OP rOMMI IN I TY H09P I TA I „ KIf death occurred in a hospital or institution
No -y.! :...y.3.r..U«L St.* give Its NAME instead of street and number;
p PHYSICIAN — IMPORTANT
2 FULL NAME W I..L.LJ..A.M G.A.I.E.L. y
a: a — - — -- ~~ ' ' " ' ' *iO
UU.
ution,
umber)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
) (Was deceased a
) U. S. War Veteran, TT/-
V i f so specify WAR) AM.S
(a) Permanent Residence. No OCEAN AjM^NUE s, WlNTHROP, MASSACHUSETTS
(City or town and State)
, . t , , j l 7, t , r j hr\ ...
i j HEREBY CERTIFY, That I attended deceased fi
v>C{ ,o M . , ■
I last saw/i/^live on ... r tr>5 „ 19.^T.T*death is sai<
at jf.jj.
d to
have occurred on the date stated above,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
../&w.pr. M/o CfribiM Xfi v [2G£ 4 v
(b) ..... _
,)ue To r rh€rm , £& i/r-
lc) AnTB^/o UttfteT ft A
other i & e-v'* trmfi. M/^7^(PL/c
SIGNIFICANT ' ^
CONDITIONS AO
INTERVAL
BETWEEN
ONSET AND
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
malb
9 COLOR
White
10 SINGLE (write the word)
.MARRIED . .
WIDOWED ARP I ED
DIVORCED
UNKNOWN
1 1 If married, widowed, or divorced
of Florence ML Dixon..
HUSBAND
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
1 ears Months Days
If under 24 hours
Hours Minutes
xm-
Was autopsy performed ? MM
What test confirmed diagnosis? ^im/C&L
S Was disease or injury in any way related to occupation of deceased^...!*1
If so, specify
(Signature)
., M. D.
(Address)
kkmmm
6 .Win.thr..o.o Winthr.o.p...
Place of Burial or Cremation (City or Town)
DATE OF BURIAL i^.toUtir.y. Z'}-.* 19.6.6...
7 NAME OF . , , T ,
funeral director Arthur. J..* Q...i.i.al.e.y.
address Winthroo^
Received and filed
A TRUE COPY ATTEST:
Occupation.. R.e.t.ir.e.d....FQr.e.raan
(Kind of work done during most of working life)
14 Industry
or Business:.
Ford Motor Car Co
15 Social Security No
16 BIRTHPLACE (City) fiUI’ IDOrO
(State or country)
Mass
17 NAME OF
FATHER
Joseph Gately
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
of mother Mary Ann McCabe
20 BIRTHPLACE OF
MOTHER (City)
(State or country) Connecticut
21 informant Florence M- .Cately
(Address) .... 2.4 Ocean Av.e Wi.n.thr.o.p
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed jvitfi me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other) /
GL^.LJ0la.A., fy&dJjkL
■'^^Tt^istrar) (Official Designation) (Date of Issue of Permit) ^
I
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
c-!'- I C, .
'l rj ' .
V’"
• “ , . i ■ i"fA
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. t' , j
(2) Board of Health physician* will certify to such deaths only as those "df
persons who, though disabled by recognized disease unrelated to any form of
injury, have died withoThe text goes on. The rest is in the file.