The volume, 1967
Town Clerk, Winthrop · from the Internet Archive · 574 pages · 36.9 MB
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^ATION,^
ACCOUNT BOOK
MANUFACTURERS
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Commonluealtl) of dfflaggatliugettsi
CERTIFICATE OF BIRTH
FROM THE RECORDS OF BIRTHS IN THE
TOWN OF WINTHROP, MASSACHUSETTS
Date of Birth:
Full Name of Child:
Sex, Color and if Twin:
Place of Birth:
Name of Father:
Maiden Name of Mother:
Residence of Parents:
Occupation of Father:
Occupation of Mother:
Birthplace of Father:
Birthplace of Mother:
Date of Record:
Registration No.:
July 11, 1956
Edward Joseph Jones
M, W, —
Winthrop Community Hospital
Edmund Jones, Jr.
Eleanor Mary Gallagher
114 Nichols Street, Wilmington, MA
Warehouse Man
Homemaker
Boston, MA
Boston, MA
July 13, 1656
530
I, the undersigned, hereby certify that I am clerk of the Town of Winthrop; that as such I have custody of the records of
births required by law to be kept in my office.
And I do hereby certify that the forgoing is a true copy from said records.
)RM R-301
INSTRUCTIONS
FOR
ICAL CERTIFICATE
In giving
(SE OF DEATH
do not enter
nore than one
ause for each
(a), (b) and (c)
its does not mean
mode o) dying,
as heart failure,
•nia, etc. It means
disease, or compli-
ns which caused
k.
mditions, if any,
Hich gave rise to
ove cause (a),
iting the under-
ing cause last.
Conditions contrib- .
( to death but not
ed to the terminal
se condition given
i).
Note:- Chapter 137,
cts of 1954 requires
hysicians to print or
'pe the cause or
juses of death on
eath certificates, and
hapter 48, Acts of
159, requires Physi-
ians to print or type
ame under signature.
M 3-61-930213
Suffolk
(County) j 2 f
(Summon ujpalllj of fHaaaarfjUHPttB
KEVIN H. WHITE
SECRETARY OF THE COMMONWEALTH
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Ag.-nt.
Registered No.
(City or Town) Co ■■PTy
No Win thropn Hospital s, ',h ffiESSlAiW
or institution,
street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME
Olivia Panaro ( S^amorra ) &cea??d. a
.j_. 1 (L. S. War \eteran,
(if so specify WAR)
(First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No
(Usual place of abode)
963 Saratoga St. East Bostoq,
Length of stay: In place of death years..
months.
.1.0.
days. In place of residence
MEDICAL CERTIFICATE OF DEATH
(If nonresident, give city or town and State)
ears months days.
3 DATE OF
DEATH
.IZ 'ML-
(Month)
(5 a y)
z 1..1LZ.
(Year)
4 1 HEREBY CERTIFY, That I attended deceased from
JN...CZ.U.. , 19 .LI...... to 19^/.
I last saw h..^rqaiive on ^.J.. , death is said to
8 SEX
9 COLOR
10 CITIZEN
11 SINGLE
□
□
OF U.S.
MARRIED
Female
White
YES e5 NO □
WIDOWED J
DIVORCED
UNKNOWN
B
□
have occurred on the date stated above, at .t...C m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
Cert/f tr^l
Due To
— Girf ~ r fc -»'<■ e.
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
7c/cLyS.
CMt
^Aa-
Was autopsy performed?
What test confirmed diagnosis? C.J.jat.caJ...
5 Was disease or injury in any way related to occupation of deceased? 0-0
If so, specify
(Signed) ..
&.ti£Ilftr..G£...te£.AA.aJ. M.,..2P..,.
(Print or Type Name'
, M. D.
(Address)
_ (Print or Type Name)
.'V^au- P.*^../ 19.&J..
St. Michael's
Place of Burial or Crematig
(City or Town)
Jan. 4 '67
DATE OF BURIAL 19
7 NAME OF
FUNERAL DIRECTOR Y.4. 1. ,® I *. 1 4. • ‘B.ZZ3.TQ 11&
ADDRESS '.2.2: §.§.l,.C..ti.....'S.. St,. 11.1...
Received and filed
A TRUE COPY A'
m 3 ...hsu
w**-
2? 19"
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Cgnce.z.10 Panaro
(Husband’s name in full)
12 DATE OF BIRTH
AGE 8.Z. Years.....hSZ!.Months.../ai Days
If under 24 hours
Hours Minutes
14 Occupation: y/tf}.
(Kind of work done during most of working life)
15 Industry
or Business :C.tr.i.Sf....^2.C!./..d.LL..
16 Social Security No.
17 BIRTHPLACE (City)
(State or country)
Italy
18 NAME OF
FATHER
19 BIRTHPLACE OF
FATHER (City) ....
(State or country)
.11A12
20 MAIDEN NAME
OF MOTHER
C.N.B.L,
21 BIRTHPLACE OF
MOTHER (City) XTJLLY...
(State or country)
22 Informant 1...
(Address) QA "2 SflPfltOPl
I HEREBY CERTIFY that a satisfactory standard certificate
was (jJ^d^wiUi me BEpOR^t)ie bo^^^yTtransycpermit w^s
% (Signature of AgenLohB^tJ^I^Mth^pr^ither) — '
J.
(Official Designation)) (Date of Issue of Permit)
of death
ssued:
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper— private family, cook-
hotel, etc. For a person who had no occupation whatever write none.
M '6jph
FORM R-301
be filed for burial permit
with Board of Health
or itf Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any, 1
which gave rise to f
above cause (a), f
slating the under- |
lying cause last. '
Conditions contrib- .
uting to death but not
related to the terminal
disease condition given
in (a).
100M-9-65-941327
®lj? (Eammnnuifaltlf of
1
2 SUFFOLK
lO (County)
\° W I NTHRO P
(City or Town)
(J NoWinthrop Community Hospital
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
W I NTHRO P
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
)(H death occurred in a hospital or institution,
..St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL nameA BRA H AM B.F.E..1 T.MA..N
(If deceased is a married, widowed or divorced woman, give also maiden name.)
.. ) (Was deceased a
j U. S. War Veteran,
\jf so specify WAR)..
no
(a) Permanent Residence. No. .208 G ROVER S A VE,, St WfJMTHROP^ M ASS.,
ry (City or town and State)
Length of stay: In place of death years months days. In place of residence27>'ears months days.
MEDICAL CERTIFICATE OF DEATH
i DATE OF
DEATH
3W
(Month)
3...i
(Day)
im.
( i ear)
4 I HEREBY CERT IF Y . That I attended deceased from
ZTSlML i9j£& «o 37A.M. 3 uA/....
I last saw hij&live on ~J...A...!Sl.x Sr...„ , W.k../, death is said to
have occurred on the date stated above, at 3.. a. ....m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
'b
Due To
(c)
S.tghn?fr.cant U£L tfe^ible p'
CONDITIONS SC levcth Hhr
W'as autopsy performed
What test confirmed diagno
? M.o...
gnosis ?3~r../..f..y.l...L.
rf P/S^s, i
INTERVAL
BETWEEN
ONSET AND
OEATH
/ hrcii^t
Sr *1 rS
S^VYS
STj YS
&££
7
5 Was disease or injury in any way related to occupation of deceased
If so, specify
nature) M. D.
jLLa.£..a.AlA*l.
ILUA..I33..^
(Sig
(Address) I
Maple Hill
Peabody, Mass.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL J..QJ?..#. 19.87..
7 NAME OF
funeral director JHoppis W« .BTszniak
470 Harvard St., Brookline
ADDRESS
A TRUE COPY
l Registrar)
8 SEX
Male
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR
Whit e
10 SINGLE (write the word)
MARRIED
i^f^dowed
husband "oi "RSbdd,dd;;iRubin
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE
82 v
ears Months Days
If under 24 hours
Hours Minutes
1 3 U sual
Occupation .
Manufacturer
(Kind of work done during most of working life)
14 Industry
or Business:.
Shoes
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Mw&jS.
-3223
Russia
17 NAME OF
FATHER
Louis Breitman
18 BIRTHPLACE OF
FATHER (City)
(State or country)
c/n/b/1/
Russia
19 MAIDEN NAME
OF MOTHER
Esther (unknown)
20 BIRTHPLACE OF c/n/b/l/
MOTHER (City) ’ '
(State or country)
Russia
21 Informant
Mr. David Breitman
(Address)
270 Beacon St., Boston
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial dr t/hnsit permit- was issued:
I I _ (Signature oIAgent of Boa^oPHealtb or other) / /
U.3/.A../
(Official Designation) (Date of Issue of Permit) / t
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cauae of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
>9-:
ww
d for burial permit
^oard of Health
its Agent.
iSTRUCTIONS
FOR
AL CERTIFICATE
FORM R-301
NT OR TYPE
E OR CAUSES
F DEATH
o not enter
ore than one
use for each
la), (b) and (c)
does not mean
mode o) dying,
as heart failure,
lia, etc. It means
isease, or compli-
s which caused
i dilions, il any,
ich gave rise to
\ve cause la),
ling the under-
sg cause last.
Conditions contrib- .
to death but not
d to the terminal
te condition given
>•
t-6-62.9331i.0U.
Suffolk
j° Winthrop.
(City or Town)
<
\oJ No
la ^ .2fc--4'“
(County) \ /
<v
®1jp (Hiimmmtumtltfy of fHaflaarljuflrtlH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
llWHTHROP
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
3
2 FULL NAME-/? X— /. >
(If deceased
t r i i • XT t IT ((If death occurred in a hospital or institution,
IvlX2?S xTl££ ^ St. I give its NAME instead of street and number)
Pleasant Bt. physician — important
C« , Ss sf? rt_ /(ofijMA/1 FfWas deceased a
is a mamed, widowed or divorced vdoman, giwecils# maiden name.) ) U. S. War Veteran,
\.if so specify WAR)
No
(a) Residence. No.... .8.3. Atlantic .Aye, St Beyer e.
(Usual place of abode)
Length of stay: In place of deathfl years months days. In place of residence J years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Year)
RTIF
to.
I last saw hr^alive on
have occurred on the date stated above, at ....
AnJLH EREBY CERT
o. // 2*.
hat I^attimded deceased irom
i9 Co y
death is said to
DEATH WAS CAUSED .BY: IMMEDIATE CAUSE
(a)'
//ft <w jv
Due To
(b)
Due
(c)
OTHER
SIGNIFICANT
CONDI ' tONS
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature) , M. D
Qi.j$..}s¥k./.u3..Q
— V (Print or Type Name) / /
(Address)^? Da
6 Plymouth Cemetery Plymouth N . H
Place of Burial or Cremation (City or Town)
Jan. 6, 196?
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR ..li© S 1 1 C W. Pike..
address 305 Beach St. Revere
Received and filed
▲ TRIIF. fOPY A
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
(write the word)
10 SINGLE
MARRIED
WIDOWED Wawpl
DIVORCED , rlL 1 XC'-L
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Gu'£ .maiden name of wife in full)
.Barry
(Husband’s name in full)
(or) WIFE of..
12
AGE
7 9 . Years. 3
ears. r/ Months s Days
23
If under 24 hours
Hours Minutes
13 Usual
Occupation: At Pome
(Kind of work done during most of iworking life)
14 Industry
UStrV A.
Business: NOTIC .
15 Social Security No.
024-14-74B8B
16 BIRTHPLACE (City). .
(State or country)
Franklin
N. F.
17 NAME OF
father Herman L. Sargent
18 BIRTHPLACE OF
FATHER (City)
(State or country)
N. F,
19 MAIDEN NAME
of mother Unable to Learn
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Unable to Learn
21 Informant
Harry Kirkorian
(Address)
83 Atlantic Ave, Bey ere
I HEREBY CERTIFY that a satisfactory standard certificate of death
^fil^with m^ B E F PR^p^th e^tm^a^rr transit permit was issued:
-v L- - . (Signature /Of) Agent, qf B«iri/of Health, or other) /
Jflicial
(Official Designation)
(Date ol 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
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 ofinjury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
Jl - 6 v? m
WlNTKvop MASS.
FORM R-301
be filed for burial permit
with Board of Health
or ita Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib- ,
uting to death but not
related to the terminal
disease condition given
in (a).
1C0M-9-65-941327
4 -f -f" c i.K
■fCounty)
l/lZ/A/ Trifco
(City or Town)
No
2 FULL NAME..
®l|p GUraunmtuiraltfy of fHaflHadjiuapttfl
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
...WlNIHROP
(City or Town making this return)
Registered No.
STANDARD
CERTIFICATE OF DEATH
fn / 771 f) A/ 7~ f — hj J Aj Tfi/AoP !(lf dealh occurred in a hos|)ital or institution,
to rj L /// U/l/ / d r, ly //</ / /TA Vf St J Rlve its NAME instead of street and number)
* 'T> , „ PHYSICIAN — IMPORTANT
oess/e Hi e /is us a/u L
I : _ ■ J • J 1 - .1 4 ~ ’ I \ ' AT’
4
..) (Was deceased a j * .
) U. S. War Veteran, A/ / )
(.if so specify WAR) z...
No. A LMoMT. s, IV/fr ■ //:.>:ss.
Length of stay: In place of death.^./^years months days. In place of residence^./A-ears months days.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Permanent Residence
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Day)
(Year)
■4 1 HEREBY C EJ< T I F Y . That I attended deceased from
vj /J Af » .., 19^70^0. y H-. / 19 /> J
1 last saw hf.rali ve on . -J Ot R ' le< , 19.67 death is said to
have occurred on the date stated above, at /OcoSA .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
flu p«Y fe vt s -»■ v cl <x\l e-l c^xheylc
Due T
(b)
16
^rtfEvo ^f'c- /J&xyS Disease.
Due To
(c)
OTHER
S1GNIFICAN
CONDITIO,
INTERVAL
BETWEEN
ONSET AND
DEATH
JLQHrs
. "Di pi b ktfS /He (/if* ?
v « 6 4 1 Arfax/atete ro S/2
Was autopsy performed?
What test confirmed diagnosis fa . i G Cf / >
/CMrs.
JLfrs,
5 Was disease or injury in any way related to occupation of deceased^^^
If so, specify
(Signature)
■4 ^ m. d_
(Address
(Pox BiiPy Mutual Society IS Ob o m J
Place of BuiNal or Cremation ( (City or Town)
DATE OF BURIAL iTA AS... 19 0'~7
0 ^O/ho/y At'
Mo #A/ei/A/eD Sf. SRgookL/Ne
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
A TRUE COPY A1
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FS/TlftiS
9 COLOR
to Hi nr
10 SINGLE (write the word)
MARRIED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
s* (Give maiden name of wife iniull)
(or) WIFE of /h.V.FA RmS. O.S.A'Y...
/ (Husband’s name in full)
AG Years
Months Da vs
If under 24 hours
Hours Minutes
13 Usual
Occupation
Ho o sa wife
(Kind of work done during most of working life)
14 Industry
or Business:
£±.. . Homt
IS Social Security
No /I OA/G
16 BIRTHPLACE (City) Cy-tyCSeAv
(State or country) />) A-S jT .
17 NAME OF
FATHER
TV? i nt> sh £/A/ke£
18 BIRTHPLACE OF
FATHER (City)
(State or country)
/ssl/t
19 MAIDEN NAME
OF MOTHER
F/MG’
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
’fcUsZ/#
21 Informant
(Add re?
Susa r/
0 J(q /J-Cmo/vt S±. - Wth/THfcoP
I HEREBY CERTIFY that a satisfactory standard certificate of death
was Jile^ with me BEFORE Ah# burial or transit permit was issued:
(Signature of Agem/ef Board of Heaith or otheA 7. __
' " //^/6 /
(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 OK PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
M -5
vJH-iCE OF irii:
WifcTHL
FORM R-301
be filed for burial permit \
with Board of Health ^
or itt Agent. \SsT
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode oj dying, tj_
such as heart jailure,
asthenia, etc. It means ^
the disease, or compli-
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
n;
Conditions contrib-
uting to death but not "
related to the terminal
disease condition given
in la).
r
*
Vj
100M-9-65-941 327
Suffolk
(County)
®1 jr (fnmmntmtpalli) nf fHaaaadjUBrttjB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
L WINTHROJ?
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
)° Wint.hr op
l( j (City or Town)
, n TT , , . . . ((If death occurred in a hospital or institution,
' No 17 .. HSLW thOm)K AV S St. / give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME Fr Qllk J , DO WIS
(If deceased is a married, widowed or divorced woman, give also maiden name.)
No 1.7 Hawthorn# Ave . St
5..
S1CIAN — iHrUKTAHT
.. ) (Was deceased a »t_
J U. S. War Veteran, 1»0
C i f so specify WAR)
(a) Permanent Residence. No.
Length of stay: In place of death.2 years months days. In place of residenc^Q. years months. days.
(City or town and State)
3 DATE OF
DEATH ....
MEDICAL CERTIFICATE OF DEATH
ZIZZ
(Month)
(Day)
LILT.
(Year/
A I HEREBY CERTIFY
19 to
That I attended deceased from
19
I last saw h alive on 19 death is said to
have occurred on the date stated above, at i.<?i£..(/b.m.
8 SEX
9 COLOR
10 SINGLE (write the word)
Hale
White
MARRIED ^ n
wiDowEDMarried
DIVORCED
UNKNOWN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
,p.,.!r..g..^...(^H..i.4/f4 d«.$. Lv...
. 'T' „ . / / *
( b) 5 TOU i/C. N:. £./ i tr.kC..KS.@£. .
I^e T° vs.Llsyiy.. (3m x (.^JLAa
OTHER
SIGNIFICANT ...C5
CONDITIONS
Was autopsy performed? MM
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature) ,£a M. D.
£d.A.LLll5....^
(Print or Type Name) , /
(Address) \Ul/^JhtS^Jia.^SS~ Date.NL3LU..’...#....19..M
6 Wi.nt.hr op Winthrop
Place of Burial or Cremation (City or Town)
January 7 ,p7
DATE OF BURIAL
Arthur J. O’ Haley
A TRUE COPY A
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
11 If married, widowed, or divorced ,
husband of Agn.es LaFrenier e
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
AGE
52
Years Months
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation Chauffeur
(Kind of work done during most of working life)
14 Industry
or Business:.
IS Social Security No.
16 BIRTHPLACE (City). -BO-StOnM-a
(State or country) ndSS
17 NAME OF
father Thomas J. Downs
18 BIRTHPLACE OF
father (City) Tarba,
(State or country)
*
ewf oundland
19 MAIDEN NAME
of mother Ellen Keary
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Newfoundland
21 Informant Carol Panetta
(Address) 1.7. Hawthorne Ave
I HEREBY CERTIFY that a satisfactory standard certificate of death
was >filed with m$7BEFO#E) the burial or transit permit was issued:
“Aa
nt/of Board of Health or other) J
xgzJL /
mcial 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 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.
M -6 *7 HI
WINTHROP. MASS
FORM R-301
d for burial permit
Board of Health
r its Agent.
STRUCTIONS
FOR
U CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
> not enter
re than one
ite for each
), (b) and (c)
does not mean
lode of dying,
u heart failure,
\a, etc. It means
lease, or compli-
which caused
lit i
itions, if any,
h gave rise to
\e cause (a),
ng the under-
• cause last.
snditions contrib- -
to death but not
to the terminal
condition given
12-62-934553
Olljr (Cnmmmmu'alti) of IfflaflHartjuHFttfl
lu Suffolk
lO (County)
..Winthrop.
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
.Winthrop
(City or Town malting this return)
Registered No
Bay. View ,Nur.sj,n^ Borne NAMfeln^eadboV^ee
1YSIC
2 FULL NAME.... S.al.ena G.er.trud.e......B.e.l.c.h.e.r. / (Was deceased a
• 1u. ~
lif s
No..
or institution,
street and number)
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran, TiTCi
so specify WAR) AN.V..*.
(a) Residence. No .3-4* -Bl.S.aS-STXij - ...Street st .iV.inthr.Q.p..* Mass...
(Usual place of abode) (City or town and State)
Length of stay: In place of
deathl...
years.. .6.. .months days. In place of residence years months days.
:5..Qy
MEDICAL CERTIFICATE OF DEATH
iUATEUF Oa m z / •> c ;•
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIF Y That I attended deceased from
19 3S‘...., to JA.U. 7 19 C l
I last saw h^£/{ilive on Jam 7 ...., \9. death is said tu
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
female
white
DIVORCED
UNKNOWN
single
have occurred on the date stated above, at .. ini C./#n.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ^4 A L tiSja. L.e..i7Ait/li££.
(b)e..To. i£YJu&JiJL
Due
(c)
T.°.
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
/ /M y.
24*
W'as autopsy performed? . UP
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? A/\
If so, specify
(Sign a t u re ) ^4...
ZL..oJJ1..4J4KlKrm4..
^ ) (Print or Type Name) ✓ /
(Address) /
, M. D.
6 .Winthr.Q.p Cemetery, Wi.nt.hr. op., Ms sA
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ..J&.UU&ry 1.Q * .1.9.67 19
7 NAME OF
FUNERAL DIRECTOR Al.fX.e.CL....B..» iu.ar.Sh.
address 17.1 WintiiXQ.p. S.t. ^... JtYin.th.ro p».
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
II If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
AGE1
32.
.11 >
Years Months
Days
If under 24 hours
Hours Minutes
>) i Occupation housework
• (Kind of work done duri
during most of working life)
14 Industry ,
or Business O.WH. XlOJUS
15 Social Security No. 012 -16-1939 -T
16 BIRTHPLACE (City). v/irtr;r.op
(State or country)
I1., ass
17 NAME OF
father y/arren Emerson Belcher
18 BIRTHPLACE OF
FATHER (City) BciS.t BOS t.QIl
(State or country) M U S S RO h.U 5 e • t S
19 MAIDEN NAME
of mother Elisabeth Davis
Hamilton
20 BIRTHPLACE OF
MOTHER (City)
(State or country) Bast Boston, Mass.
21 Informant E., Buster Belcher
(Address) 2.3.Q lin.c c In St * Wi.nthr.Q.p
.. I HEREBY CERTIFY that a satisfactory standard certificate of death
Mass *led . withlme BEFORE, the' t)i#ial or transit permit was issued:
(Official
of Health or oth^r)
'Adi 2.
(Date of Issue of Permit)
A TO IIC COPY ATT IT QT-
!/
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
M 1 0 ^7 PM
FORM R-301
d for burial permit
loard of Health
its Agent.
iTRUCTIONS
FOR
iL CERTIFICATE
T OR TYPE
OR CAUSES
DEATH
not enter
■e than one
se for each
i, (b) and (c)
does not mean
ode of dying,
r heart failure,
!, etc. It means
•ase, or compli- ^
which caused
\tions, if any, i
i gave rise to f
came (a), f
g the under- l
cause last. I
editions contrib- .
j death but not
to the terminal
condition given
$ljf (UnmmmuuraltJj nf iilaflHarljUHFttH
1
(County)
)° /y/ *//£<?/ f.
ly (City or Town)
\<
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
i WINTHROP
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
7
No ...,/AJ.
2 FULL NAME f7.A..§..S....£.tJ.... A J~ Q..(2..
(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 (Was de
\ u. s. w
\if so spe
deceased a
ar Veteran, / / A
specify WAR)/'!/..??-..
/XS d &/// C y A K Jr St Ur ///Ttf/Ps/?
/ (City <
(a) Permanent Residence. No
(Usual place of abode)
Length of stay: In place of death^^years months days. In place of residenc
02
or town and State)
ears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH y. U.IlMu.
(Month)
(Day)
mi
( ^ ear)
4 I HEREBY CERT I F Y That I attended deceased irorn
.CL.Jt % i9..ie±. to UdioUa^ 2 i9 J?Z.
I last saw h.liz^live on ^Tf^9....2.....'A 19^7, death is said to
have occurred on the date stated above, at .... CMR .m.
(a)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
KG^kzA.x..od
lbV.2fflQ.)py^
Due To
(c)
"xTt
-r^
OTHER ; /
SIGNIFICANT Z&JrdSL*'.
CONDITIONV [j
.ulc.t
INTERVAL
BETWEEN
ONSET AND
DEATH
3) hi in
90
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature)
s'. _
2
ir Tv
... M. D.
%A/?J..£r.
eNa„e)
(City or I own)
DATE OF BURIAL ^...Zt.-Af... //.
6
Place of Burial or Cremation
FUNERAL DIRECTOR/^^ ZA
ADDRESS
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
11 If married, wi
HUSBAND
WIDOWED
SownV/^/^
•d, widowed, or divorced . ^ ^ /
of /^AA’Af/^.P...
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
AG
Years Months
Days
If under 24 hours
Hours Minutes
Occupation
(Kind of work done during most of working life)
14 Industrv
Business. shfTt y.TV./t.A.
IS Social Security No... Q &. / ~ A /./
16 BIRTHPLACE (City).
(State or country)
-7$Z
7- SS-f
Ass
17 NAME OF
FATHER £
18 BIRTHPLACE OF
FATHER (City)
(State or country)
/ TAjL \j
19 MAIDEN NAME
OF MOTHER sZ/S/Y
C rj/p0> 4 <?
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
/ / * A
21 Informant /*/CJ......£±&.//fJE.. /?.A.A.
(Address) /MmzAAy.... 4.^ u/'yT'yzp^'
I HEREBY CERTIFY that a satisfactory standard certificate of death
was^led w//th me I)£FORljv the bui^ly^r transit permit was issued:
, (Signature of Agent of Board of Health 'or other)
£-0.. . . aA&zIaaL (//p./.At..
(Official Designation) ‘ (Date of Issue of Permit) if1
-63-9363I48
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cauee of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
I* 10 -P7P*
FORM R-301
be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode o) dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib- .
uting to death but not ^
related to the terminal
disease condition given
in (a).
100M-9-65-941327
(CximmmuuFaltlj uf fHaflBarijujBrttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
[WINTHROP
(City or Town making this return)
Registered No Cji
((If death occurred in a hospital or institution,
St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME.
(If deceased is a m^ried, widowed or divorced woman, give also maiden name.
dscf
St..
(a) Permanent Residence. No .
Length of stay: In place of death...O... years.. ^...months. ,^s.days. In place of residence .Q ..years'^ months, ^^days.
(City or town and State)
3 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
<P-
(D/y)
F JfiiK
Month)
JJZT
(Year)
4 I H/E R E B Y C E RTIF Y
f ojis , 19 ^0 to t
1 last saw Ic^alive on
have occurred on the date stated above
hjjt . I attended deceased J,rgm
19.1
ed trom
re, at A
19*'../', death is said to
DEATIJ-.WAS CAUSED BY: IMMEDIATE CAUSE
(a) ...
.teT/U biSF&B
Due To
(b)
fAo C f SM
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
/So tt-E
— fe
INTERVAL
BETWEEN
ONSET AND
DEATH
iMoS.
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specif
(Address)
^ TTn —
5lace of Burial or Cremation (City or Town)
Place
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Q...
.19 vr /
ADDRESS
,;:;3 Maa
Received
19..
A TRUE COPY A'
I Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED . ,
WIDOWED yj
DIVORCED
UNKNOWN £
II If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ~
(Husband’s name in full)
12
AGE
Q .. Years Months.
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER /
18 BIRTHPLACE OF
FATHER (City)
(State or country)
l OF 37 ' 0 -y — V
tv)
(T
19 MAIDEN NAME
OF MOTHER
br
20 BIRTHPLACE OF
MOTHER (City)..
(State or country)
21 Informant 2L c Au.
(Addressl / U feeC C}Ah-* (Zff .
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me PEFORE^the burial or transit permit was issued:
cy- •
Signature ol Agjjnt of
^
(Official Designation)
(Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
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.
JW - 9 ’67 am
jirtCt Or i.t, , l'vVN «.
WINTKrtOP. MASS
FORM R-301
be filed for burial permit
with Board of Health
or itf Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given
in (a).
Suffolk
(County)
Qtyr (Emnmmuuraltlj nf HlaaHarijUBFttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHROP
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
fe ...Winthrop
(City or Town)
■tr- 4 V-5 tnrr T\.Tn-r»o-i rur Urvmo ((If death occurred in a hospital or institution.
No .YlKXllg Imr.S.A.jrig n.Oie St. \ give its NAME instead of strec ' ’
9
street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME .M.i.XffiU DaVlS I'eldman /(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ( U. S. War Veteran, Krr\
V if so specify WAR) JN.U..C
(a) Permanent Residence. No. 8.Q Sagamore Avenue. st Winthrop, Mass •
(City or town and State)
Length of stay: In place of death....2..years months days. In place of residence45.years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
IXA/vArt-y % Wi?7
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
/.z- y - i9 cr ,o 6 7 ».
I last saw h£f^ali ve on f...T.. bfjJL 19 , death is said to
have occurred on the date stated above, at J O /?m. INTERVAL
' BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b) .........
6
fi-CCT fc* l ...ft lSx^L-SjL o J/S
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed? ..Afl t
What test confirmed diagnosis?
IMO.
5 Was disease or injury in any way related to occupation of deceased To
If so, specify
(Signature M. D.
A> ^c.C.Ap IMP? M £>
.. i * (Print or Type Name) . _
PJ£iTt*r.. sf' jPate.^.Tr..^...™ 19.6 ^.,
(Addre
6 C.r.er,at.ipn,.Wpodlawn .Crematory , Ev
Place of Burial or Cremation (City or Town)
date of burial January 12 ..*.1.96.7 19..
7 NAME OF , - „ , . . . ,
funeral director ...A.iXP.ed x).* Marsh,..
address 174 .lin.t.h.r.Q.p St.., Winthr.Q.p,..
personal and statistical particulars
8 SEX
female
9 COLOR
white
10 SINGLE (write -the word)
.MARRIED WldOW
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Abraham. Eel dman
(Husband's name in full)
12
AGE. 69iearslQ. Months 1 Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
..housekeeper
(Kind of work done during most of working life)
14 Industry
or Business:
private homes
15 Social Security No.. [removed]
16 BIRTHPLACE (City) BOSt.CH
(State or country) M&8 3 a
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
Morris Davis
Poland
19 MAIDEN NAME
0F MQTHER Jennie Rose Nathan
20 BIRTHPLACE OF
MOTHER (City)....
pyip -fc (State or country)
Russia.
21 Informant .. Mary. ....Welsh erg
(Address) 8.Q S;.iganor.e Ave ♦ Winthr.c p.
I HEREBY CERTIFY that a satisfactory standard certificate of death
[V,a 3tSs>(iled ^(Ith me^EF^^^fl^^rial.or Uanyt permit was issued:
( (Signature of Agent 9/ Board /jf/Health or either)
(Official Df^sigiiation)
ent at Board pf/Health or olher)
(Date of Issue o/ Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
M I 1 IS7 PM
\*T
Ciffi
'WNTHrtCP. MASS.
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
be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart jatlure,
asthenia, etc. It means
the disease, or compli- .
cations which caused
death.
Conditions, it any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib- -
uting to death but not
related to the terminal
disease condition given
in la).
1 OOM-9-65-941 327
ft / V
ulljr (Emnmmtumtltfj of fHaflaadjuarlta
[% Suffolk V/./°
! ®
KEVIN H WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Winthrop
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
Winthrop
l^j (City or Town)
Winthrop Community Hospital ((If death occurred in a hospital or institution,
'a. No „ , i St. j give its NAME instead of street and number)
Concett/z (naine*o) physician — important
2 FULL NAME M*!. . ..Sa.IltarpiO /(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran, UTQ
f. if so specify WAR).
to
specify WAR)..
East Boston, Mass.
(City or town and State)
Length of stay: In place of death years months^!, days. In place of residence.*) 0 years months. days.
, . _ _ . , .. 120 Bremen St .
(a) Permanent Residence. No St..
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
v i I i Y
Q (Month) * (Day) (Year)
HEREBY CERTIFY
/ 0 ]9 (e Lp ' to *i
1 last saw h.Ar:alive on . . 1 TL.. Y , 19.CrZ, death is said to
have occurred on the date stated above, at t
, That I attended deceased from
lL/Y__ t 1 i a 7
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
G*
CY
Due To
(b)
Ca*ctnoma of Xivet e MetaAtaviA
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
y^c-.
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? y\<>
If so, specify
^ (Pript or Type Name) . ,
i9 Al.
(Address)
ADDRESS
holy C'M'id Cemete/Uf NalAeyi
67
Uincent K. Rapine
9 CheLaea St. t [ait
Place of Burial or Cremation
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Received and filed ...,jC\ .fit
Shi
"ZT
A TRUE COPY AtTEST:
JAN1 6 1967
^Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
{emote
9 COLOR
white.
10 SINGLE (write the word)
MARRIED
WIDOWED J; /
DIVORCEDa'tt>0'fceea<
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of $Q4eph Santaepip
(Husband’s name in full)
12 ryj If under 24 hours
AGE .... .TTYears Months Davs | Hours Minutes
13 Usual
iJoHAPjotie,
(Kind of work done during most of working life)
14 Industry
or Business:
at home
15 Social Security No
none
16 BIRTHPLACE (City).
(State or country)
fio4ton.f Mn A4S
17 NAME OF
FATHER
9*an.k Maine/co
co
H
18 BIRTHPLACE OF
FATHF.R rCitv)
z
(State or country)
Otatbf
06
<
19 MAIDEN NAME
OF MOTHER
9*anc.eA Qodnbi
Pm
20 BIRTHPLACE OF
MOTHER (Citv)
(State or country)
Ptatif
21 Informant 9**tk SQrltOA.pio ( 40Yl)
(Address) .... 120 &*emen St, , [a4t
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with^ne BEP&RE the bprial.or transit permit was issued:
J
cvj7 j (Signatpre^e/ Agety4fEBoard of H«djh or other) )
*h'.'.
(Official Designation)1 (Date of Issue of Pertjnt)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cauae of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
JW JR 1 6 V AM
WlNTHftOP. MASS.
X
J-
FORM R-301
pc C
P H
be filed for burial permit
with Board of Health
or ita Agent.
X r}
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
P H
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cauae for each
of (a), (b) and (c)
a
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
•r
■P
*T“
P
Conditions, i) any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib-
uting to death but not “
related to the terminal
disease condition given
in (a).
(=1
Q 1
>
Cl
Tl
a
(City or Town making this return)
<)o Winthrop '}^Jr standard -
03 (CityorTown) CERTIFICATE OF DEATH Reg.stered No 11
P /~i -f- + o re 0 2or>V ((If death occurred in a hospital or institution,
.•4r..l..7T. y..y...w...y..9’G>.M St. I give its NAME instead of street and number)
CD
0
lOOM-3-65-939763
®1j? (Emnmnmuntltlj nf HaaHarfjufipttB
Suffolk
(County)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
No..
PHYSICIAN — IMPORTANT
2 FULL NAME Mary Si.Qr.gi.Q (.M.arot..t.a.)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
il
(Was deceased a
U. S. War Veteran,
f so specify WAR)..
no
(a) Permanent
Residence. No. Ill Oo&tage Park..M.* st. Winthrop....
tW2..6
Length of stay: In place of deattfi:..V^..years months days. In place of residence..^ (gears months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3K2I!hof. January 20, 1367
(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 .»h.:..««!..C!.../^
DEATH WAS CAUSED BY: IMMEDIATE CA
(a) ..
USE
Due
(b)
xl.cU..£. {.Q. ihA...L^y..s....l .(...
£?e u s es: .
OTHER
SIGNIFICANT
CONDITIONS
{ji,’
Ztlo
VU<_^
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? H.O...
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased^..?.
If so, specify ya.....* ... ./fl.
(Signature)
r«drX-, M. D.
.Q.iiaxl.e..a Li.'b.erman.
WflStee BofflWtifgBfcth 1/2 V67
« Hoiy,....Or.fts.g fismaisiy. MaXien...
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .Jan., 2.1,
lfc'.i
7 NAME OF
FUNERAL DIRECTOR
14? Winthrop St., Winthrop
ADDRESS
tt3
Received and filed V....i...T.^)yT. ..jt'..*;.
'■'L' Jgwg-'
ggfc
A TRUE COPY
I Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIED
(write the word)
widowed
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of...An&e.l.Q....S.i.Q.r.gl.Q
(HusbantPs name in full)
AGE
.5.7.
Years .3 Months
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation . ...hO.US.8Wif 6
(Kind of work done during most of working life)
14 Industry . ,
or Business:, a t h.Q.Die..
15 Social Security No.
16 BIRTHPLACE (City)....W.l.W±hr.Q.p..
(State or country) o o p
17 NAME OF
FATHER
Lorenzo Marotta
18 BIRTHPLACE OF
FATHER (City)
(State or country) T 4- ,
19 MAIDEN NAME
OF MOTHER
J-3-
Maria Vitello
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
,, _ , Angelo Giorgio
174 Cottage Park Ad. , rtintbrol
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
«s filed with rte BEFORE the burial or transit permit was issued:
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.
■* 23 flfll
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
be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any, i
which gave rise to f
above cause (a), r
stating the under- i
lying cause last. '
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given
in (a).
1 00M-9-65-941 327
< Suffolk
(County)
W I NTHROP
(City or Town)
®ljr (Emnmnnutpaltlj of fHaABarijUHPtta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
W | NTHROP
(City or Town making this return)
Registered No.
12
No..
UlMTWOnP COMMUNITY HOSPITAL „ ((If death occurred in a hospital or institution,
W I. NTHROP L U MM.U N ' 1 . T. U 1 t!'Ve "S NAME mstead of s,reet and number)
2 FULL NAME.
Mrs. Elizabeth Bradford («C ame-ro-n )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
J (Was deceased a
) U. S. War Veteran, A/ A
'.if so specify WAR)..../, r .1/..
(a) Permanent Residence. No I...6. I.A.FTS AVENUE St ^ I N T H R O P , M A S S
(City or town and State)
Length of stay: In place of death years months 4?..days. In place of residence^ffiyears months days.
MEDICAL CERTIFICATE OF DEATH
3 death >F. January 2 1 , ! ? 67
(Month) (Day) (Year)
4 I H E R E II Y CERTIFY, That I attended deceased, frgm
.3-/
.tterCee...')r'b 19 ia , ^ ... .
I last saw heTltlive on ./ death is said to
have occurred on the date stated above, at .. ...m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
'b)e ' ~£C ‘-i72'v7< 4 <* jf-yfirf-lBiAirf J y/?j
£ Lc tFT
/j- &+K 7“ ZV-S
(c)e ' </ £ Ftfl CrC/l <4
SIGNIFICANT 'P / £ A C 1 c I TVS
rnvninnvc *
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
pm
v*>cs
i/iO
Was autopsy performed?/*.
What test confirmed diagnosis OL/ /vjC&L
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature)
...MXR.O.N N. I) I N.« f.,., m. u.
vc.' ¥) * ryi &
7 (Print or Type Name) / / _
(Address) ....222 P.L.EA.S.A.NT S.i ate
Winthrop. Mass .
6 AAA AAA
Place of Buriaror Cremation (City or Town)
ALd+L. A.JA..
DATE OF BURIAL
FUNERAL DIR ECTC ) /./' /j//A & y
ADDRESS
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
FOULe\ /Z///TA
10 SINGLE (write the word)
MARRIED
WIDOWED
11 If married, widowed, or divorced
HUSBAND of ,
(Give' maiden name of wife in full)
(or) WIFE o M+S.£f.*P.
(Husband's name in full)
AGE
r.. Years Months Days
If under 24 hours
Hours Minutes
,J &sU» /?£STAiJM/rr VMZ
(Kind of worK done during most of wor
orking life)
14 Industry
Business
IS Social Security No..
1ft BIRTHPLACE (City).
(State or country)
r
17 NAME OF
FATHER QAA/Sr/ZAA/f. Asm/Z/A/f
18 BIRTHPLACE OF
r> i ix i n ilall ur y^-x _ y- . y/ , ,
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER //AAV
BIRTHPLACE OF < £ rf.C T /} // An r
MOTHER (City) P %.Z 7 V.L f /. l.U.
(State or country)
yg/f/KC/ff
2 , u*™. /m *M44>& . MAMS.
(Address) .. At) &oS7t>A
I HEREBY CERTIFY that a satisfactory standard certificate of death
BEFORE the burial or transit permit was issued:
ywas filed with me
lUtiA/AA.ASr.......
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT ,
SERVICE NUMBER
RULES OF FRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths 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 o; death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cauae of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
JW 23 B7 PM
WINiHROP, MASS.
ed for burial permit
Board of Health
r its Agent.
ISTRUCTIONS
FOR
Al CERTIFICATE
FORM R-301
VT OR TYPE
E OR CAUSES
F DEATH
o not enter
>re than one
use for each
), (b) and (c)
does Hot mean
node of dying,
is heart failure,
i a, etc. It means
tsease, or compli- .
which caused
iitions, if any,
h gave rise to
e cause (a),
ng the under-
t cause last.
mditions contrib- ^
\fto death but not
I to the terminal
a condition given
B-63-9363U.8
L
(Cammmiuiraltlj nf HHafiaarliujafltH
iw Suffolk
(County)
W inthrop
(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.
LT
No.
Cl Iff* Nlvr<Hrnr Hrwwa 170 01 •? Of A tr<» U,f death occurred in a hospital or institution,
nOJSO cursing r.cmo, I /■U UllII «V()t,| K,ve lts name instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME..
George A Lawson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Bellevue
(a) Permanent Residence. No I.Q.6 ... BeH.<We*U ...A VC, S, W inthrO? , MaSS.
(Was deceased a «»
J U. S. War Veteran, r'O
V i f so specify WAR)
(Usual place of abode)
(City or town and State)
Length of stay: In place of death years months days. In place of residence. 3 . ...years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
(Month)
(Day)
(Ye
R E B Y C, E_R T I F Y
to
4 I HEREBY C. E h
. I1®!
That 1 attended deceased, from
ir 3 19 bj......
I last saw h/^4^hve on . 3W .Tr.,3.... 19.^...3leath is said to
have occurred on the date stated above, at ...^ /ir
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
/frfpETZrl o
Due To
(c)
r.°. U J Tft~ d-tiy*. .f ...
other /vu, tr
SIGNIFICANT (V V* &
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
t
Was autopsy performed ? M.o :
What test confirmed diagnosis?
-frb
5 Was disease or injury in any way related to occupation of deceased/r.<
If so, specify
-
(Signature) LXP~—/ M. D.
M.y.EcA/..
(AddnM>
a' /i/Vfi
• l'C?./..
6 Wpodlawn Cem , Everett
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
•Tan, 26, 19. 67
7 FUNERAL DIRECTOR Maurice W Kirby
ADDRESS
W inthrop
Received and ^ -J...., JAM 2 6 1967
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
widowed Widowed
DIVORCED
UNKNOWN
11 If married, wiAjujaLor
HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
12
AGE
79
Years Months
Days
If under 24 hours
Hours Minutes
13 Occupation Carpenter
(Kind of work done during most of working life)
14 Industry
or Business.
Bldg* Constructor
01 0-07-3879
15 Social Security No... . ^ , _ __ .
16 BIRTHPLACE (City) St.John's,
(State or country) N.B.
17 NAME OF
father Robert E Lawsou
18 BIRTHPLACE OF
FATHER (City)....
(State or country)
St. John's
N.B.
19 MAIDEN NAME
OF MOTHER
Georgia na Gray
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
St* John's
N.B.
21 Informant MrS Ethel 0’C 07^11
106 Betl-eveau Ave.Winthrop.Mass
Bell p vue ' . . : —
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
, filed Atth me/BEFOBE .the b\irj*l or. transit permit was issued:
igent o( pofiisd of IJe»lth ’or oth^r) .
(Official Des^natibn) ’ (Date of Issue of ^e/mit)
g We ,of /f Ken
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
.1
r"' ~
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons),thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
• woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
r
FORM R-301
be filed for burial permitA
with Board of Health J
or its Agent. vU
X
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode o) dying, Qj
such as heart failure, ,
asthenia, etc. It means
the disease, or comfili- ^
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
staling the under-
lying cause last.
7 H
Conditions contrib- Cl i~ .
ting to death but not
uting
related to the terminal
disease condition given
in (a).
i
'4/
100M-3 -65-93 9763
So fA Ik.
(County)
£ (JL) 1
(City or Town)
2 FULL NAME..
$lj? (Enmmmuuealtlj at HaBBarljuaetlB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
| W1NTHR0B
(City or Town making this return)
Registered No.
11
No..
J / r . . £ ft „ Si — f (If death occurred in a hospital or institution,
..*.... ./.. St. ( give its NAME inst
..S.....q...L.Q..^...o.aj S.RaP..{^.Q...
tead of street and number)
PHYSICIAN — IMPORTANT
{?
(Was deceased a
U. S. War Veteran,
so specify WAR)..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Permanent Residence. No. O. CoTLt<l Si * UJtroTri-Hop
Len.lh ot slay. In place of death^J^>.ars months days. In plact ol t . It, 1 months days
M
0.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
'of
(Month)
3 o
(Day)
IA...L.J.
(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 .
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
Zl^M p..\c..ie.j..K..^..ft...6../.« <c/«<
To/l h, a f~ i
Due To
(c)
iO t H f f
t V 4' O
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
~m..
5 Was disease or injury in any way related to occupation of deceased rb
If so, specify
(Signature) M. D.
(tHA.AjLC..S. \.L.L3..A...^.M.S.^
(Print or Type Name) A
(Address)
MqADTJ... So/IA £\/€f2jTff
Place of Burial or Cremation (City or Town)
FC'-iJ :67
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
A TRUE COPY A1
\ ^ \ tO <a_s U i Ccm CUttscoi
;z2Sm3aa:zzi::
l Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
/\A
9 COLOR
(AJh'f*
10 SINGLE
MARRIED
(write the word)
UNKNOWN
II If married, widowed, or divorced r\ , / <C" 1 a i
HUSBAND of tD.I.la. ^..(.t. tA.b...
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE .V 't'Years Months Days
fa.
If under 24 hours
Hours Minutes
13 Usual
Occupation.
pries s&z
(Kind of work done during most of working life)
or Business:.
15 Social Security No.... a C-jo ' JAsj
16 BIRTHPLACE (City).
(State or country)
T&i 55 f A
17 NAME OF
FATHER
4 ft ft A HA^ ./VI OS He 5 U4C/KO
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
(3/3 <-
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
ASS
/4
21 Informant
(Address)
SAfZdtt. /PluL(>L
/f eon±c LUt*nii£vP
I HEREBY CERTIFY that a satisfactory standard certificate of death
wasJiled with me .BEFORE the buriaLor transit permit was issued:
oZ- — """ (Signature of _Agent of Boutdaji Heaith,« other) 7 ~7
f/A/./..LZ
(Official Designation/) ^ (Date of issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
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.
FB 2 - •67 AM
WINTHPOP. MASS
FORM R-301
be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
Conditions contrib-
uting to death but not '
related to the terminal
disease condition given
in (a).
1 00M-9-65-941 327
SUFFOLK
(Cmmttmuuraltlj of
£\ KEVIN H. WHITE u.
*»-'• ^ Wl NTHROP
l <£
/S'
(County)
W I NTHPOP
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS (City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
15
WlMTHPno r n M M 1 1 N I TV HciQDITAI , (d* death occurred in a hospital or institution,
\o, No.”.L™. “T.H □.y..5..C...!....L.O.k St. ( give Its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 FULL NAME il!.. F_L .0 PEN C.F J K f Y /(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) \ U. S. War Veteran,
*,if so specify WAR}
,, _ f p M 146 Cottage Papk Rd
14 50
Length of stay: In place of death years months days. In place of residence years
Wi nthrop Mass
(City or town and State)
..months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
M
Month) J (Day) /
w-
4 I iH E R E II Y CERTIFY , . That 1 attended deceased , from
...CJAA* U&ti-' 2L 19 £-2
I last saw h/S^alive on J..C!. , 19^£?-/^death is said to
have occurred on the date stated above, at 'iZlrxA. ^m. I INTERVAL
BETWEEN
ONSET AND
DEATH
i? t>A- y.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a )U?eeQ£/H. /TFMcPfiMGE-PT'
l w FT- w -rMrpZ££ . * ' - -
Due To,
(c)
'6rZ. H £.&./*:Uh.£ ft Ai..?. if
SIGNIFICANT hLrtrtEAAL BsfZQ-MXo y
CONDITIONS ^ iH E.
3y
$' 64 yi
Was auto))Sy iierformed ? £ll © ..
What test confirmed diagnosis? h.A&4tJtiXc&nf.
5 Was disease or injury in any way related to occupation of deceased? m
If so, specify
(Signature) - , M. D.
tsu.cd. o .
(Print or Type Name) II r .
( Address) '?^...Q4^.T.^..pTX...^.^„ Date.4.4LL..^.'...19..(p!.A
VO rH
6 .....Winthrop. Winthrop
Place of Burial or Cremation (City or Town)
Feb. 2 1967
DATE OF BURIAL
7 name of Howard S Reynolds
FUNERAL DIRECTOR t
ADDRESS
Winthrop Mass.
Received and filetPTTN
mum
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE ~ (write-,the word)
MARRIEIOingle
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
, rF82 .. 4 .. , 10 n
AGE Years Months Days
If under 24 hours
Hours Minutes
n usual Teacher retired
Occupation
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No
Public school
[removed]
16 BIRTHPLACE (City).
(State or country)
England
17 NAME of
father William S Key
18 BIRTHPLACE OP
FATHER (City)
(State or country) England
19 MAIDEN NAME
OF MOTHER
Rose Hopewell
20 BIRTHPLACE OF
MOTHER (City)..
(State or country)
England
21 Informant
(Address)
Lois Haywood
1171 Boylston St. Boston
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE tlje burial or transit permit was issued:
/. . -t . J. ^4- 's'- / .
(Signature of Agent of Board of Heaith or other)
(Signature ot Agent ot Board ot Heaitn or otr
//$.l/J..2
(Official Designation)
(Date of Issue Of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form ofinjury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
FORM R-303
To be filed for burial permit
with Board of Health
or it* Agent.
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SUFFOLK
(County)
WINTHROP
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
IjM.tllHROE
(City or Town making this return)
Registered No. ... ±G
Bn. route to Wlnthrop Community Hospital s,
BETSEY DREW TOWER f(Was deceased a
2 HULL NAML J (l S War Veteran AT /n
(First Name) (Middle Name) (Last Name) [if so specify WAR)....1?:...®
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Wilton, Connecticut
City or town and State)
(a) Permanent Residence. No .^7....^.?.®?..®....®?.™* St
Length of stay: 1 of death years months days. In place of residence1—. ^ years months
..days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 SeI?hof January
31, 1967
9 SEX
10 COLOR
(Month)
(Day) (Year)
Female
White
41 HEREBY CERTIFY
that I have investigated the
death
11 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED CMnn.1<»
UNKNOWN O-LIlg-LC
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully J
Fracture of skull. Cerebral
contusion. Fracture of jaw.
Accident.
12 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
S Accident, suicide, or homicide (specify)
Date and hour of injury ,... JahUary...3.1, 19. 67,
3:40 A.M, y Pe
IF ACCIDENTAL, was injury causally related to the death? .A.S.S?.'
where did Winthrop, Massachusetts.
(City or town and State)
Did injury ^arm» ’n industrial place, or\n
public place ?
(Specify type of place)
L,p.rnyer of Passenger in motor-ca:
NatuStruck trdg°.w did injury occur?)-
Injury
usband’s name in full)
If under 24 hours
Hours Minutes
during most of working life)
t Airlines
090-38-91+18
Newton
(Signei
Mi.cha.el. 'A .....Luo.ngQ,.\“
_ (Print or\
'Bui.try)C"yJ Mhhh'o
l^NAME OF
father Frederic D. Tower
19 birthplace of TVT^w+-on
FATHER (City) .r..®.HE9“...
(State or country) M&SS a
20 MAIDEN NAME
of mother Marth a Chapman
21 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
New Bedford.
Mass •
(Address) BOStOIl yi Date
7 Forest Hills Crematory Boston
Place of Burial or Cremation. (City orMihitSlS
22 informant Mr •Frederic D. Tower
(Address)
DATE OF BURIAL
'Febpuag ?9 17 Ruscoe Road, Wilton, Conn.
8 NAME OF
FUNERAL DIRECTOR
ADDRESS ...B..Q..3..t.Qn
Received and filed
J.S .Waterman & Sons
A TRUE COP
It
(Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the bupial or transit permit was issued:
(Signature of Agent of Board of Health or other)
'Uir.lii-y Alzj.kL
(Official Design4tion) (Date of Issue of Permit) /
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
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 hgve 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 natui’e 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 sux-gery).” “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 cauge 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.)”
FORM R-301
T - OF - TOW
To be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode oj dying,
such as heart latlure,
asthenia, etc. It means
the disease, or compli- ^
cations which caused
death.
Conditions, il any,
which gave rise to
above cause (a),
slating the under-
lying cause last.
Conditions contrib- .
uting to death but not ^
related to the terminal
disease condition given
in (a).
GJfjr (Cnmutflituiralll) nf HlacBarijUBPtlB
_ A
E M.££J.LK J'
/f'Vtumtv \ Hi 1 -i
'Ht&i
100N.5-6I*-938000
(County)
§ koizM \
(City or Tqwn)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
17
(City or Town making this return)
2 FULL NAME
Registered No.
00072
f(lf death occurred in a hospital or institution,
St I give its NAM K <n«tcad •street and number)
PHYSICIAN — IMPORTANT
ceased is a married, widowed or divorced woman, give also maiden name.)
f <\Y is deceased a
)!' S War Veteran, iy A
\i f so specify \VA R ) :
(a) Permanent Residence. No. 3£L /?A s. Pls/wrrf/ffi/P
' (( in t.r to
Length ol stay: In place of death years... .^.months days. In place of re-adeinc c.u ■ (/ months
vn and Stale)
. days.
3 DATE OF
DEATH ....
MEDICAL CERTIFICATE OF DEATH
7=3E£5
PERSONAL AND STATISTICAL PARTICULARS
(Month)
(Day)
(Year)
4 1 HEREBY C E R T 1 F Y,. Chat 1 yatpwide
* = rrjpc-l 7
I last saw lic^alive on | I V V _ ' •
7 CL*.
Jed deceased from
, 19
death is said to
8 S| \
9 COLOR
HAlf
A/hjt£
have occurred on the date stated above, at .
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
oj ! kf toil (\\r[
Due
(b)
Due To
(c)
■^mtrwCLlf Lfiz-ep c~
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWFEN
ONSET AND
DEATH.
IEATH/9
Was autopsy performed?
What test confirmed diagnosis?
*
S Was disease or injury in any way related to occupation of deceased
If so, specify ... .
(Signature)
(Address)
■jz-Zte # ^ 1 ^
t i . (Priiy^ ofjTypc Name) < a (
Daie/^.H,..vTf
M D.
1m
FT
6 &.../MTM/P6/?. w/Mr/y/?tJ>e
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 FUNERAL DI R ECTO R /tf.A.tf/f!./... CA. HZ....
a DDR ESS /&//>/ AfrtfA
Received and filed
A TRU
IAN 6 1967
(Registrar)
10 SINGLE (wrile the word)
MARRIED
WIIX )\VKD
DIVORCED
UN KNOW!
,V\ A(Aj?ft/£b
11 If married, widowed, or divo/ced
HUSBAND of Srf ffA
M.AAAA
(Give maiden name of wile in full)
(or) WIFE of .
(Husband's name in full)
Months. Days
If under 2 4 hour-
Hours Minutes
U Occupation &JbgUteMZ£i. f-
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No
16 BIRTHPLACE (City). S4
(Stale or country )
17 NAME OF
FATH KK
18 BIRTHPLACE OF „ _ . .
FATHER (City) A’Z/V'S ^ S 4 A/r Af
(Slate or country) (? S+/PSA/A/ *
19 MAIDEN NAME
OF MOTHER
I'/V/t'/fd.jKAC .
20 BIRTHPLACE OK , _ , „
MOTHER (City) /rff. /A/ J A A 4A . W.
(State or country) yy 0 f // O 4-/P4 A//V4-
2. infer, nan.N/V^/^J $ Sf /J A
(Address) fAC.. 6# ACM. M.
3^EFORE the^^rial^y-tgysit^fjB'^^'a
(Signature of Agent ' T^--* •• '
, M-l
cial Designation)
id certificate of death
rjuiL-wat issued:
ol Health or other)
{Date of issue ol Permit)
PY ATTFSTi
TRUE COPY ATTEST:
FEB 27 *67 h*
, v.fe ji- in. I OWN CLERK
WINThROP. mass.
FORM R-301
- - OF 'T'OTXn
To be filed for burial permit
with Board of Health
or it* Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter,
more than one
cauae for each
of (a), (b) and (c)
Tkis does not mean
Ike mode of dying,
tuck as keart failure,
astkenia, etc. It means
Ike disease, or compti- ^
cations wnick caused
deatk.
Conditions, if any,
vskick pave rise to
above cause (a),
statini Ike under-
lyint cause last.
Conditions contrib-
uting to deatk but not '
related to Ike terminal
disease condition liven
•n (a).
Funeral Director
Pleaee uee only
BLACK Ink.
100M-9-65-941327
SUFFOLK
(County)
'5 BOSTON
(City or Town)
(Hammamuraltlj of fHaBflarijUBPtlfl
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
00126
Registered No _
No..
Maeseehweetfe General Hoepltal BAKER MEMORIAL
((If death occurred in a hospital or institution,
..St. | give its NAME instead of street and number)
2 FULL NAME.
Domenic T. Cardillo,
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
/(Was
\ U. S.
(.if so
as deceased a
War V'eteran,
specify WAR)..
No
(a) Permanent Residence. No 14 WadSWOrth Avenue, Win T Op Massachusetts
(City or town and State)
Length of stay : In place of death years months .fi,, days. In place of residence .... 5 years months da\s.
3 DATE OF
DEA TH
MEDICAL CERTIFICATE OF DEATH
T.
January
(Month) (Day)
twt
(Year)"
4 I HEREBY CERTIFY, That lw#ttcnded deceased from
December 28 19. 66 ... to January 3 , 19 67
last saw h ij^iive on January 3 19 67'eal^1 sau( ,o
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
male
white
WIDOWED m_rr4
DivoRCF.nmarr:Lea
UNKNOWN j
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE
(a> Chronic Cor Pulmonale
1^03 p
LTE CAl
USE
KiUnonary ffibrosis
Z'Asbestosis
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
1 Year
12
AGE 66 T ears
Months
Days
„ 13 Usual ,
10 lears Occupation Retired
(Kind of work done during most of working life)
^ca s 14 ess ********************
Was auto|>sy performed? X.®.®
What test confirmed diagnosis? ... Autopsy.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
ype N4me
... M. D.
lOVyl
(Print or Type N4me)
(Address) Aaa't. Olr., Ma*«. Gais'L Ha*p. Date 1-4- 6 7... 19.,
6 Winthrop Cemetery , Winthrop
Place of Burial or Cremation (City or Town)
date of burial January...../ 19. 67
7 NAME OF , . _ _
funeral director Anthony P. Rapino
address 9 Chelsea. St», East Boston
PERSONAL AND STATISTICAL PARTICULARS
II If married, widowed, or divorced
husband of ...Josephine. Ruggiero.
(Give maiden name of wife i
(or) WIFE of
in full)
If under 24 hours
Hours Minutes
IS Social Security No. 0 3 2 ~ Ql— 5 0 04
16 BIRTHPLACE (City) Boston, MaSS,
(State or country) ' ’
17 NAME OF
FATHER
Michael Cardillo
18 BIRTHPLACE OF
FATHER (City)
(Stale or country)
Italy
19 MAIDEN NAME
OF MOTHER
Carmela Fortunato
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Italy
21 Informant
(Address)
Josephine Cardillo (wife)
14 Wadsworth Ave., Winthrop
Received and filed
A TRUE COPY ATTEST y ,
•MSI 1 0 1967,
t Registrar)
I HEREBY CERTIf
gas filed with me
Uiat a satisfactory standard certificate of jjeath
ransit permit w*s issu
(Signature ol
(Official Designation)
u . JAS t .
'ORE the bur
Agent
l i
(Date of Issue of Permit)
if Board of Health or other)
i....6./ Cj.jLZL ..._
i
^ TRUE COPY ATTEST:
ffg l 7 t* A«A
/ u.
/|0/ \T
[t| b]
wFHCfc 0)= Irib iVm»« oLIRK
WINTHROP, MASS,
FORM R-301
JT - OF - TOW
To be filed for burial permit
with Board of Health
or it* Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter-
more than one
cauae for each
of (a), (b) and (c)
Thit dot s not mean
the mode of dying,
such as heart lailure,
asthenia, etc. It meant
the disease, or compli- ^
cations which caused
death.
Conditions, il any,
which pave rite to
above cause (a),
staling the under-
lying cause last.
Conditions contrib-
uting to death but not '
related to the terminal
disease condition given
in (a).
Funeral Director!
Please uee only
BLACK Ink.
10GM-9-6S-941327
ulljp (Cmmnomuraltli of fHaooartiuopftjB
SUFFOLK
(County)
BOSTON
(City or Town)
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
19
(City or Town making this return)
C0301
Registered No.
Meeaeckueette General Meapltal BAKER MEMORIAL UH dea,h in 3 1h"s'>i,al or institution
No ... St. | give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name Angelo P. Screnci
(II deceased is a married, widowed or divorced woman, give also maiden name.)
I (Was deceased
\ U. S. War Vet<
L i f so specify W
Veteran, At -
AH) /VP.
(a) Permanent Residence. No 51 Sargent Street ; S,. WinthrOp, MaSS
(City or town and State)
Length of stay: In place of death years months (. days. In place of residence years months
MEDICAL CERTIFICATE OF DEATH
3 DATE OK
death January.
(M onth)
11
(Day)
.1.9.67
(Year)
’ ^ I H E H Y C I 1 F Y , l ^IWft tended decease^ ^rom
last saw h.ilUlive on Jan.. 11 19.67, death is said to
have occurred on the date stated above, at 12 I iO a m-
DEATH WAS CAUSED BY: IMMEDIATE: CAUSE
Coronary Heart Disease
(a)
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CON Dl l IONS
INTERVAL
BETWEEN
ONSET AND
OEATH
6 yrs.
w
Was autopsy performed?
What test confirmed diagnosis? Clinical
5 Was disease or injury in any way related to occupation of deceased?
If ho, specify .......
.^Signature)
CKorU* L. CUy, M.D.
layy l
(Print or Type Name)
(Address) Ass'*. OLr., Mas*. Co»’l. Hasp. Date Jan • 1.1.... 19.6 7,
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
M
21 Informant
Received and filed
JAN 13
f'/ K /*/£ :
A TRUE COPY ATTEST:
r;
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
/r?cU^
9 COLOR
10 SINGLE
MARRIED
(write the word)
WIDOWED /}A . ,
DIVORCED
UNKNOWN 1
II If married, widowq
HUSBAND
■d, widowej*».cii divorced.. . / _ rt
of d £.* avA.L.#A£..
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
AG f .. Years . Months. ..y^Days
If under 24 hours
Hours Minutes
13 Usual
Occupation . .?
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No
(dilres
I . HEREBY CERTIFY that* a satisfactory standard certificate of death
,was file® with meTTFPORE the burial or transit permit was issued’ .
SiA- ‘LLLY
(Signature of Agent of Board of Health or other) s ' ^
tMLd>.. LL
£ [Date of Iatuc of Permit)
( Signal tffe of Agent
(Official Designation)
l TRUE COPY ATTEST:
FEB 2 7 t7 Mf '
FORM R-301
JT - OF - TOwiki
To be filed for buriel permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MIDICAl CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cauae for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli • .
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
staling the under-
lying cause last.
Conditions conlrib-
uling to death but not ‘
related to the terminal
disease condition given
is (a).
I00H-9-6S-941327
Suffolk r^y
(County) m Iklty
Boston
ullje (Emmmmuiealtif nf iHanaarljuapttfl
KEVIN H WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or Town making this return)
co^ro
(City or Town)
Oz-iT limhllC Miirci nbr Horn#* „ Idf death occurred in a hospital or institution,
No... V..Q 4» UTU.Q.U.S nurslllg D.S'.’.MS. St.( give its NAME instead o( street and number)
Registered No
ititution,
number)
PHYSICIAN — IMPORTANT
2 FULL NAME Anastasia Lawler .
(If deceased is a married, widowed or divorced woman, give also maiden name.)
..) (Was deceased a
J U. S. War Veteran,
L 1 f so specify WAR)..
pecify
Winthrop
No
(a) Permanent Residence. No. -5 Q Tr IdCnt AV ©., St
Length of stay: In place of death years months days. In place of residence years months flays.
(City or town and State)
3 death01!. January....
(Month)
MEDICAL CERTIFICATE OF DEATH
1967
(Year)
(Day*
4 Ilf E R E 1) V' CERTIFY , That 1 attended deceased from
7>4aZ 19 &G. to Zl/i W r... pi J /
I last saw h'^vtive on JOtf/t /,// 1^.7 death is said to
have occurred on the date stated above, at jm.
8 SEX
9 COLOR
10 SINGLE
(wrile the word)
Female
White
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Single
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANli
CONDITIONS
•ANjji M P ? v Jr e u 5 1 y e // wo.
s h. / eno /7 c H £ s.
INTERVAL
BETWEEN
ONSET AND
DEATH
4
12
If under 2 4 hours
AGE yijAfars
... Months .
Days
Hours Minutes
PS
Was autopsy performed ? .... ,
What test confirmed diagnosis? C*l 1 A e a l
S Was disease or injury in any way related to occupation of deceased YlLy
If so, specify ■'*
n
(Signature) . , M. D.
Ch.ar.les MD.er.man
, (Print or Type Name) / 1 .
(Address) Q .P yM./t SSlialo
6 Winthrop. Winthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL Januar y 17 ,m67-
7 FUNERAL DIRECTOR Arthur JL. Q.'.Mley.
address Winthroo r Ma-br.,
Received
*nd„filed 18
A TRUE COPY ATTEST*
• Registrar)
PERSONAL AND STATISTICAL PARTICULARS
1 1 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s namr in full)
13 Usual
Occupation .
Cook
(Kind of work done during most of working life)
or Business: Church Rectory
IS Social Security No
i6 birthplace (city) Char les t own*.
(Stale or country) MaS S
17 NAME OF
fatiuk John Lawler
18 BIRTHPLACE OK
■FATHER (City)
(State or country)
Charlestown
Mass
19 MAIDEN NAME
OF MOTHER
Catherine G. — McAleney.
20 BIRTHPLACE OF ,
MOTHER (City) iJOr t laUCl
(State or country)
Maine
21 Informant R0b.£5.r..t....W.£i 4. JU QX* Sr
(A,i.iress)5Q Trident Ave., Winthrop
HEREBY CERTI^V that a satisfactory standard certificate of death
A- /was tiled with me BEFORE the burial or t/anuL permit was issued;
allMi.
/ ) (Signature of Agent of Board of . Health or other) _
U '\Lt, /£ /?£ 7
(Official Designation) (Datr'bf Issue of Permit)
A TRUE COPY ATTEST:
^rrlCt OF IH l 10 WN CURtf
WfNJHROP, MASS,
FORM R-301
led for burial permit
I Board of Health
or its Agent.
INSTRUCTIONS
FOR
5ICAL CERTIFICATE
INT OR TYPE
ISE OR CAUSES
OF DEATH
do not enter
!more than one
cause for each
(a), (b) and (c)
Air does not mean
mode o) dying,
as heart failure,
' nia , etc. It means
disease, or compli-
ms which caused
!*•
mditions, if any,
'•ich i gave rise to
ovt cause
sting the under
ng cause
Conditions contrib - „
? to death but not
ed to the terminal
se condition given
).
any, i
e to (
(a), }
ider - l
last. )
OUT - OF - TOWN
1 •=y>*U o\ ic
« t
/U3 x
c
RCounty)
Inject.
(City or Town)
ulljr Crnnmmuuraltfy nf
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
ChelsesC 21
(City or Town making this return)
Registered No.
ti K 71
Uf I J
rv'
Soldiers’ Home Hospital j (if. death occurred in a hospital or institution,
No St. j give its NAME instead of street and number)
\ Frank. r Anthony WESSLING
STANDARD
CERTIFICATE OF DEATH
2 FULL NAME <CVV'''
(If deceased i
Tank A Antron^ WhbbLIJNG . r physician - important
...tO-'5 Sa ^ - /(Was deceasi
ised is a married, widowed or divorced woman, give also maiden n^me.) \ U. S. War V<
s \if so specify
(a) Permanent Residence. S t .
Length of stay: ...years... V... months.^ ..days. In [dace of residence years months days.
deceased a .
eteran, , , . —
WAR). OO \
or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OK
DEATH
7
CL4m\
( Month )
(Day)
( a r ) *
4 I HEREBY C E.R T I F Y That I attended deceased from
Dec . 12 19.66 to Jan.. 21 , 19.67.
I last saw h.lTahve on 19.6.7, death is said to
S n JlO
have occurred on the date stated above, i yft-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
a)
Due '^-Atherosclerotic heart disease )
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
'Ik. ( Ckrbhlclrer^^
'ANT
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? . DO ~~
What test confirmed diagnosis? ... Clinical.
S Was disease or injury in any way related to occupation of deceased,^. .
If so, specify
(Signature) , m. d.
(£fcse.e..ht„ Rr.oaTo.Lti
_ (Print or Type Name)
(Address)
Jloly Cross Cem. . /Malden, Mass
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
A TflUF COr*'- A
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
TOaU>.
9 COLOR
11 If married,
HUSBAND of
(or) WIFE of..
Uj h i [&,
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED, /,,»,« A
UN know*,/; Ua&G UjQd'
, V IN AnUVI
-Arsenault.^
'-(Give maiden name of wife in full)
(Husband’s name in full)
AGE*) 0 Years C) Months. ^ Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
14 Industry
or Business
Qs^MR.. C^ckiA^Mr^-iXU
(Kind of work aone during mast bf working life)
— , ■ V u
.^Not known
15 Social Security No Q 1) ~~j /k ** (p6 ..Sgf
16 BIRTHPLACE (City).
(State or country)
• C£) o
■'rn^A. i a‘
17 NAME OF
FATHER
18 BIRTHPLACE OF'
FATHER (City)...
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
&
■-|k.
■O-T) Q-IP
SiiJL&JL
<6<d4^L
21 Informant^..^.'
(Address)
0(*kA ts ^
(3 VldLuu ■ VfHAva
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fUed with me BEFORE the burial or transit permit was issued:
f)&§.^l....f^..0.L.. A.f.H*AM V&.4JL.
(Official Designation) (Date of IsAtTe of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE N..VV r\: 3..-.
RANK, RATING
ORGANIZATION AND OUTFIT... U.‘..S.:....CL^ .‘rXDM
SERVICE NUMBER.....\..1^..^r.^..LV..^.^’.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) A"— ding physician! will certify to such deaths only as those of persons
to whom mey have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physician* will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
tnjrry, have died without recent medical attendance or whose physician is
absent from home when the Cc: ".cate of death is needed.
(3) Me ’ical Examiners will investigate and certify to all deaths supposably
due to ry. These include not only deaths caused directly or indirectly by
tram m (including resulting septicemia), and by the action of chemical
(c . 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.
S nt of Cause of Death. — Physicians: see explanatory instructions
on lace 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
ne entry in this section for every person aged 10 years or over. If the occupa-
tion bad been given up or changed, or if the deceased had retired from business,
re; rt the kind of work done during most of working life even if retired. Chil-
dri a not gainfully employed may be returned as at school or at home. For a
worn e only occupation was that of home housework, write housework.
For a per i engaged in domestic service for wages, however, designate the
occii; tion by the appropriate terms, as housekeeper — private family, cook-
hotel, etc. For a person who had no occupation whatever write none.
A TRUE COPY ATTEST:
FEB 24 «7mi
OFFICE OF i fit jOWiH Q
WINTHROP. MA§8t
. “‘‘H ;;yy ;
-Mil 2 4 4237
FORM R-301
be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any, i
which gave rise to I
above cause (a), r
stating the under- l
lying cause last. }
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given
in (a).
100M-9-65-941327
SUFFOLK.
]C (County)
\o WINTHROP
(City or Town)
®1jp (Unmmnniufaltij of fHaoaarfyuBPttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
WINTHROP
(City or Town making this return)
Registered No.
22
WINTHROP COMMUNITY HOSPITAL S (If death occurred in a hospital or institution,
No St. ( give its NAME instead of street and number)
2 FULL NAME .(5.1 0.R.G.E J ,W A.PL..A N B
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN — IMPORTANT
) (Was deceased a " A/
1 U. S. War Veteran, mm /•}
V i f so specify WAR)
(a) Permanent Residence. No. IP B 0 W DO IN STREET St W I. .NT HR OP, M AS S A C.H U SETTS
v . (City or town and State)
23 %(,
Length of stay: In place of death years months.TT.'Tdays. In place of residenc years months days.
MEDICAL CERTIFICATE OF DEATH
3 death0!. February I , 1967
(Month) (Day) (Year)
I H E R E, B Y CERTIFY .TT hat I attended deceased from
7"AV- . /r g a b , / »AZ
" ‘ 1
I last saw h.y'.kg^ive on ....
have occurred on the date stated above, at S-..Q...t.
19*?/
:L>
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
C£j Y&.i hi <3^
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
ArAie...
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? yC. 5^..,
What test confirmed diagnosis ?
5 Was disease or injury in any way related 'to occupation of deceased
If so, specify
(Signature)
d/±AE.k.C.-$ 1 ./..aM£A.<A..M,.
M. D.
/rA.i.>.A.Q.J>
(Print or Type Name) j / r
(Address) . Date.. 19.K.yC.
I Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WH I TE
10 SINGLE (write the word)
MARRIED „ , ^ ^ ^
widowed M A R R 1 ED
DIVORCED
UNKNOWN
1 1 If married, widowed, or divj
HUSBAND of
(or) WIFE of..
(Give maiden name of wife in full)
(Husband's name in full)
12
AGE'
£.3... Years ^3 Months^*?
Days
Usual
Occupation
If under 24 flours
Hours Minutes
(Kind of work done during most of working life)
Industry
or Business:
Social Security No..
C2 3 - G.9-..
BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
vx
t
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
21 Informant
(Address
ssi 3C /fa
I HEREBY CERTIFY that a satisfactory standard certificate of death
- • ■ griaj or transit permit was issued:
Heilth or other)
xjcmus
8TT
03 I
SOflHTH I W
JATIS80H YTIHUMMOO ^OAHTHIW
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERv1cS£.J.?. *
m&mpwmm-v
RANK, RATING
T3-35TT-8— M-l’OtJWO'Q— 0£
£•§
ORGANIZATION AND OUTFIT
§WICE NUMBER....3T.ttfw .3.J-A-K «..l
‘\r
RULES OF PRACTICE
3 O v,\
A
t "
The fulfillment of the purpose of these laws, calls for the observance of the
following rules of practice: m"*1 — ' " C: W
(1) Attending physician* will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physician* will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by \
traumatism (including resulting septicemia), and by the action of chemical 1
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related <o occu-
pation, the sudden deaths of persons not disabled by recognized. dtstase, and
those of persons found dead. ^
, { 0 )( ‘b
VK
Statement of Cause of Death;— Physicians :
on face side of standard certificaieof death.
see explanatory instructions
Statemeni of Occupation. — Precise statement of occupation is very impor- k — JCv
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person afee\f 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 forking life even W Retired. Chil-
dren not gainfully employed may De 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
be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any, )
which gave rise to f
above cause (a), r
stating the under- 1
lying cause last. *
Conditions contrib-
uting to death but not
related to the terminal
disease condition given
in (a).
X
1 00M-9-65-941 327
2 .S..U.EE.Q.L.K
|G (County)
fe WINTHROP
FULL NAME
(City or Town)
V..J C T Q R C...LP.R.I..A.N..I
©Ij? (Cmmnnmupaltli of UtaaBadjuaetta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
WINTHROP..,.
(City or Town making this return)
Registered No.
23
J (If death occurred in a hospital or institution,
..St. I give its NAME instead of street and number)
^/i/r4i(i//WiNTHR0P C0MMUN,TY hospital
PHYSICIAN — IMPORTANT
J (VVa
(If deceased is a married, widowed or divorced woman, give also maiden name.) A U. S
(.if so
79 WiNTHROP St RE FT St W i NTH POP _f Mass .
as deceased a
S. War Veteran,
specify WAR)..
/K>
(a) Permanent Residence. No.
Length of stay: In place of death years months. ,.\e... days. In place of residences /-years
(City or town and State)
..months davs., '
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
F EERUAPY
(Month)
E f 1967 WM-
(Day)
ms
(Y ear)
I attended deceased |rom
:eased from
...
..jXf.dV.!. to.
I last saw hT^lhve on <7\ , death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
dororurj..
(hE Eg. -tl* r.L..S~$te.MU£-
Due To
(c)
S I GN'f F I C A N I'fP. Ulhu> . h.4:YX..<l/. i t* id F
CONDITIONS V ( 1
INTERVAL
BETWEEN
ONSET AND
DEATH
& hi*
Was autopsy performed?
What test confirmed diagnosis:
5 Was disease or injury in any way related to occupation of deceased?
If so, speo
(Signature^^p^^Lfe^^^^^E^^.iTVnEEkTry^T^rE^ M. D.
(Address) ( i^z.
(City of Town)
Place of Burial or Cremation
DATE OF BURIAL
Received and filed"N
A TRUE COP p' ATTEST :
I Registrar)
PERSONAL AND STATISTICAL PARTICULARS
i SEX
MALE
9 COLOR
WH I TE
10 SINGLE (write the word)
MARRIED
WIDOWED ..add 1 r* d
DIVORCED MAPR I ED
UNKNOWN
11 If married
HUSBAND
ied, widowed, oA'fiivorced ~ /9 - ZfZ —
) of msxirsZx
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in full)
AGE
.Years... Jr Month.-
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
(Kind of work done during most of working life)
14 Industry
or Business:
Social Security No..
£ 2 a c c '9 ^ y-C.f.J
BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN N
OF MOTHE
20 BIRTHPLACE O
MOTHER (City)
(State or country)
I HEREBY CERTIFY that a satisfactory standard certificate of death
, filed^with mwBEFGRE the .burial or transit permit was issued:
SPACE FOR ADDITIONAL INFORMATION
DjVTE of entering military service
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
*
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death.— Physicians : see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, howSver, 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
iled for burial permit
i Board of Health
or its Agent.
INSTRUCTIONS
FOR
ICAl CERTIFICATE
INT OR TYPE
SE OR CAUSES
OF DEATH
do not enter
jnore than one
ause for each
(a), (b) and (c)
is does not mean
mode ot dying,
as heart failure,
nia, etc. It means
disease, or compli-
ns which caused
nditions, if any, j
ich gave rise to f
ove cause (a), r
ting the under- l
ng cause last. I
Conditions contrib- _
to death but not
•d to the terminal
te condition given
-9-63-936314-8
ll Mfikli
(County)
®1|? (Enmmnmuraltl| of fUasHarljuflrttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
WINTHROR
(City or Town making this return)
CERTIFICATE OF DEATH Reg.s.ered No
/ / / c* /) Jj /Q-r A-* /) i(If death occurred in a hospital or institution,
'a, NoA./..p?. .r \.f'...y'..jr..l...y.. Al... AA St. \ give its NAME instead of street and number)
2 FULL NAME..
(If
m £Mld4 £. IMA/ldrf. (,w„ d,
deceased is a married, widowed or divorced woman, give also maiden name.) \ U. S. W
Vif so spe
PHYSICIAN — IMPORTANT
deceased a
ar Veteran,
specify WAR)
(a) Permanent Residence. No. /../.A Oav/Fr /?/) Mass.
(Usual place of abode) (City or town and State)
Length of stay: In place of death. ,^^!years months days. In place of residence<j~^Zyears months days.
MEDICAL CERTIFICATE OF DEATH
3 DEATH JF... ...February
(Month)
9 19.6.7.
(Day) ( ^ ear)
4 I HEREBY CERTIFY, That I attended deceased from
S.ept.* 2 i96.Q , to...Feb* 9 1967
I last saw hillklive on Feb..* 8 196.7, death is said to
have occurred on the date stated above, at ... 7: lQa ..m. I INTERVAL
BETWEEN
ONSET AND
DEATH
J? yrs
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Advanced rheumatic heart
(a) disease ...with aortic- sten —
Os is — and mitral insufficiency
Due To ^
(b) none
Due To _
(c) none.
OTHER
SIGN1F1
CONDITIONS
Embolism to splenic
sicn! fica NTartery with infarctio
12
If under 24 hours
AGE^AVears
Months
Days
Hours Minutes
3 wks
i
Was autopsy performed ? HO.
What test confirmed diagnosis ? clinical & lab «
5 Was disease or injury in any way related to occupation of deceased? Elf)
If so, specify
(Signature) .. f. jrtrers , M. D.
M....T.r.a.un.s.t.e.xn.,..J.r(...lM.vD......
(Address)73 Bartlett" 2-10 1967
( . rr.wtnthrop/kass i z:
6 ^ AT/YA/P Y/A YA//^M/Py//A>
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
//..
■ VYs-S-
FUNERAL DIRECTOR /V/tMzCY: A' 'f'&Z?'
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED
11 If married, widowed, or divorced
HUSBAND of
/ (Give maiden name of wife in full)
(or) WIFE of '...
(Husband's name in full)
(K'fnd of work
work done during most of working life)
14 Industry
or Business.
A/) #-
15 Social Security No..
16 BIRTHPLACE (City).
(Stale or country I
r — 3*St 0/Y
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
TVS/
//fjjF ' a^/yA
19 MAIDEN NAME
of mother
20 BIRTHPLACE OF . a r r s.
MOTHER (City) AAT £ -V /J
(State or country)
21 Informant
M dt/? y A/1 A A// ■ A/a
(Address) y/A CAYY/FZ: /PA YA/Y yZA/Z/AY/yA..
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed? with me BEI^DRE -the burial, or transit permit was issued:
RE -the buy
bard^^Health or other)
(Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING 77.£..G....u£.
ORGANIZATION AND OUTFIT M.F..
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.
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
R-302
iS... Suffolk
IQ (County)
Gftjr (Commomufialtlj nf fHaflaarljuarlta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
Jtevj9i*e
-ity or 1 own m;
'as®
COPY OF
CERTIFICATE OF DEATH
(City or" Town 'making this return)
25
Registered No.
(° Revere
jjj (City or Town)
ir- ! _ ((If death occurred in a hospital or institution
a. No .Y..X..0.W. M .8.11. .0.3?. St. ( give its NAME instead of street and ni
lumber)
2 FULL NAME Philip L.« McterS-OIl ..... /<W|S ^e«^eeiraan
(If deceased is a married, widowed or divorced woman, give also maiden name.) j if so specify WAR)
no
(a) Permanent ResideiH NSuirnni.t A.ve.*
xt Winthrop-
Length of stay: In place of death! years months days. In place of residendj-3-.years months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February
(Month)
(Dajf)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Nov.. \9.93. to Fkfe., 11 19..6.7
I last sawMJ?... alive on , death is said to
have occurred on the date stated above, ..m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cerebro vascular
occIur>f on
Due
(b) .
ToCerebral^ artf rio-
5-CTETUSI'g
Due To
(c)
spgnutcant Pulirioji ry tuberculosi
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
6mons
?yrs.
W
s
3yrs
Was autopsy performed? ..
What test confirmed diagnosis ? .GUnl.C.&l..
5 Was disease or injury in any way related to occupation of decea setfO.
If so, specify
(Signature) .Qnfi..r.l.©.s ..lb f rma n. , m. d.
Dr...
..Date^/13. 16..7.
6 Wlnthrop Cemetery 'Vin thrpp
(City or Town)
..February 1.5 47.
Place of Burial or Cremation
DATE OF BURIAL
7 FUNERAL DIRECTOR ..Z.Olf I!..?.
ljt-7 ^.inthrog- St,..., Winthr.Qp,,.
ADDRESS
Received and fi
fi 81967
■ ' WiJL .
or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
■/hi te
10 SINGLE (write the word)
MARRIED
WIDOWED
DIVORCED , A
unknown*'* i CD wed.
1 1 If married, widowed, or divorced
husband of ....Mary E.. Doyl e
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
AG
S5...-Y
ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation : ...M.Q.fc.Q.OJ^n
(Kind of work done during most of working life)
or Business: JEQ.s.t.Dn... .Elevated
15 Social Security No..
16 BIRTHPLACE (City) Mai Can
(State or country)
Hi — s-
17 NAME OF
FATHER
? a r. > » j c k J . And e r a on
18 BIRTHPLACE OF
FATHER (City) ftal-Way.
(State or country) Tr>f>l anrl
19 MAIDEN NAME
OF mother FI 1 en ,?i nn e g a n
20 birthplace of
MOTHER (City)....
(State or country)
Glasgow.
Scotland
21 Informant .Philip. L.». Anderson, Jr.*
(Address) 6 ftsii.th... y.y,;..H.inghain
A TRUE COP
ATTEST:
—
DATE FILED
(Registrar of City or Town where death occurred)
February II4, , 196.7.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
m 5 ’67 A*
xT 12
/»/ V\
fsf =-3 j
OFFICE OF i i.
W!NTi
FORM R-301
> be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any, )
which gave rise to f
above cause (a), f
stating the under- I
lying cause last. '
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given
in (a).
b
100M-9-65-941327
©Ije (£mnmnmii?altij nf UiaBaadjufirtlB
Suffolk
(County)
Winthrop
(City or Town)
No
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
tKVINTHRQB
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
1 rj -p, n , ((If death occurred in a hospital or institution,
JL ( f3l fliyr* H. ot» St. ( K|ve l,s NAME instead of street and number)
PHYSICIAN — IMPORTANT
2 full name . Marion - A -vKelleher
(If deceased is a married, widowed or divorced woman,
give also maiden name.)
) (Was deceased a
) U. S. War Veteran,
l if so specify WAR) AN”..
(a) Permanent Residence. No. .11, S, Winthrop, MaSS.
(City or town and State)
,6.9. ...years months.... days. In place of residence f^.^years months days.
Length of stay: In place of death
MEDICAL CERTIFICATE OF DEATH
death February 11.,
(Month) (Day) (Year)
4 Jr-v H EREBY CERTIFY', That I attended deceased from
c ' r, r * r f
dJ. 19.T.3 ..... to Q/l//.
I last saw hl£j&live on ^ // 0/ ., 19.1 Pf,
have occurred on the date stated aDove, at ^ O * , m'
19,
8 SEX
9 COLOR
Female
White
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) s Y iT-'k4V:|
Due
(b)
Due
(c)
OTHER
SIGNIFICANT
CONDITIONS
L.Q..M.YrL :
INTERVAL
BETWEEN
ONSET AND
DEATH
( <2-
To s' 1 1'/ p ro f y£ £> ssettse. ^Lf r 1
Was autopsy performed? S\j.. r
w as autopsy periorineu / /••-
What test confirmed diagnosis? (L. /Lel . cLfLX. /.....
5 Was disease or injury in any way related to occupation of deceased? jf/..
If so, specify
'W
(Signature) . . ^ .6^ , M. D.
....Char.l.e.s.....Lib.e.r.ra.an
^IPrint or Type Name)
y) : jl.'C
F// < ,iPrint or Type Name) / /
(Address) ^6./.^../../i9.\.fet.f^..yd:/viV.^).A....Date...»^^...//. .y/l9.6..j?
6 St. Mary's Randolph, Mas s
Place of Burial or Cremation (City or Town)
February 14 67
DATE OF BURIAL
7 FUNERAL DIRECTOR Arthur J, 0 ' Mal.ey
ADDRESS Winthrop,,, Mass..
Received and filed .
FEB 13
TTEST:
^Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED.
DivoRCEDMarried
UNKNOWN ACU.
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Leo Ke lie her
(Husband’s name in full)
(or) WIFE of..
ag.69 V
ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation.
Housewife
(Kind of work done during most of working life)
14 Industry
Business: Own Home
15 Social Security No.,
16 BIRTHPLACE (City) WlnthPO-P
(State or country) _ g
17 NAME OF
father Joseph L. Vi sail
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston
Mass
19 MAIDEN NAME
OF MOTHER ^ V J. CrOWlfiV
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Boston
Mass
21 Informant Leo ..Kelleher
(Address) 17 Paimyr a Street Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
filed with me^BEFQRE /the bunal or transit permit was issued:
2k WziJLiii/
\ u I 1 1 _ _ ! J . . ' \ / TV • 1 T . . I I ) . V
(Official Designation)
(Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE .
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
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
> be filed for burial permit
with Board of Health
or its Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart latlure,
asthenia, etc. It means
the disease, or compli- .
cations which caused
death.
Conditions, ij any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
£4
Conditions conlrib-
uting to death but not -
related to the terminal
disease condition given
in (a). £
<c
X
w
100M-9-65-941327
Suffolk
(County)
atyp (Cmnmmuiifaltlf of fHaBsadjuartta
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
JliQf
(City or Town malting this return)
27
No..
STANDARD
CERTIFICATE OF DEATH Registered No,
(If death occurred in a hospital or institution,
2 FULL NAME
Winthrop
(City or Town)
1 h 11-1 j * 3(11 death occurred in a hospital or institution,
JLrr W clX CLGIHoU? -AV© St. ( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
James A. Kir ley
(If deceased is a married, widowed or divorced woman, give also maiden name.)
14 Waldemar Ave.
(Was deceased
| U. S. War Vete
\.if so specify W
Veteran,
AR>..
N...O...
St..
(a) Permanent Residence. No.
Length of stay: In place of death.Jj?.. years months days. In place of residence^ Oyears months days.
Winthrop, Mass.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
death!. February 11 , 196?
(Month) (Day) (Year)
4 I HERE II Y CERTIFY, That I attended deceased from
Sent. 13 ,19 64~, to Feb- 11, , 19. 6.7
I last saw h.. liB ve on ..Jan., 3, 196.7, deathis_sa_id to
have occurred on the date stated above, at .9 ..IQ ... .3...J11 .
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
Male
White
WIDOWED
DIVORCED
UNKNOWN
Single
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)Ar.terio.sclarotic.. h.ear.t disease .
(Ib)e.TS.e.ne.r.alize.d....ar.t.eri.o.s.cl.er.D.sis.
Due To
(c)
OTHER
significant none..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
' 12 oO
If under 24 hours
’* AGF/O Years
.... Months
Days
Hours Minutes
5 ye ar
no
Was autopsy performed?
What test confirmed diagnosis? ...C l£nical..Xindinas..
5 Was disease or injury in any way related to occupation of deceased
/JoEn F.*....C.allins, M. D..
(Print or Type Name)
(Address) 27 Benrdn!it.Qn....3.:k.a Date Eeh.* 13..,.....'
Revere , 11 •a ? s fi chus e 1 1 s
6 Holy. Gross Malden, Mas s
Place of Burial or Cremation (City or Town)
DATE OF BURIAL February 1.4, »...6.Z
7 FUNERAL DIRECTOR ... Arthur J... .O.'.Mal.ey
address Winthrop., Mass
Received and
131967
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)
13 Usual
S Occupation.
Retired Sewer Dept
(Kind of work done during most of working life)
14 Industry
Business: Tov;n of Winthrop
15 Social Security No..
16 BIRTHPLACE (City). EaSt BOStOn
(State or country) — Mass
17 NAME OF
FATHER
James Kirley
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
of mother Maria Murray
W 20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Ireland
21 Informant Agnes Murphy
, 14 Waldemar Ave., Winthrop
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death
Xwas filed with-me BEFORE the burial or transit permit was issued:
Z^....(*j. -
, \J (Sigpature of Agepyof Board of Health or other)
(Official Designation) (Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(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 Cauie of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write housework.
For a person engaged in domestic service for wages, however, designate the
occupation by the appropriate terms, as housekeeper — private family, cook —
hotel, etc. For a person who had no occupation whatever write none.
t
FORM R-30
1
To be filed for burial permi^V
with Board of Health
or its Agent.
INSTRUCTIONS ^
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
3
v
&
*
>1-
*
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given
in (a).
a,
r
X
a.
100M-9-65-941327
L Suffolk
IQ (County)
Winthrop
(City or Town)
(Unmmnnuintltlf nf fHaaflarijUflfttH
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
No..
114 Lincoln Street
STANDARD
CERTIFICATE OF DEATH
(City or Town making thre return)
Zb
Registered No.
2 full name Richard B. Page
(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
/ (Wa
T U. S
(.if so
as deceased a
S. War Veteran,
war veteran, nm* r\
specify WAR) H.ijf.....g£..
(a) Permanent Residence. No. U4 LinCOln Street St IlnthPOP.., M&SJL*
(City or town and State)
Length of stay: In place of death,13years months days. In place of residence IRears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
F~ W. b ,
(Month)
(Day)
AWT..
(\ ear)
4 I HEREBY CERTIFY, That I attended deceased from
19 to 19
I last saw h alive on 19. U. death is said to
have occurred on the date stated above, at ... UlQJrA .in.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) D c, ■■■■&•.■ fWty \ vj
...iL&LW&.S...
(b)e..I°/i2 Ka.toLX.cii (o.
Due To
(c)
Ui us/Jrftflcj M
OTHER ffj
SIGNIFICANT ..I
CONDITIONS
Jr.U.4..
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^
ki !
" ... ^ ^
(Signature) M. D.
.Charles Liberman r-
(Print or Type Name) / / .
(Address) 21.8 Shore Drive Date A./.U.J.. :67
xlnthrop. Mass.
Winthrop Cemetery, Winthrop
r'1 ~c ^ tion (City or 'fown)
February 14 ,1967 19..
Place of Burial or Cremation
DATE OF BURIAL
7 FUNERAL DIRECTOR Richard C , Kirby , Inc
APDRE&L7 Bennington St . tB,Boston
Received and filed ./V J
A TRUE COPY ATTEST
FEBT3
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED**-, j
DivoRCEoMarrlea
UNKNOWN
11 If married, widowed, or^iivorced
HUSBAND of
dowed, or divorced
Pearl I. Hemp el
(Give maiden name of ■
(or) WIFE of..
wife in full)
(Husband’s name in full)
AGE
11
Years Months. .
-Days
If under 24 hours
Hours Minutes
Occupation. Brakenian retired.
(Kind of work done during most of working life)
or Business:. B & M. Railroad
15 Social Security No.. 028-0^-3125'
16 BIRTHPLACE (City). Brighton
(State or country)
17 NAME OF
FATHER
Harvey W. Page
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Danvers
Mass
19 MAIDEN NAME
OF MOTHER
Catherine Davis
20 BIRTHPLACE OF
MOTHER (City) BOStOn
(State or country) Uaniu-
2i infant Mrs... Pearl I. Page-wife
(Addres' 114 Lincoln St . , Winthrop
JEREBY CERTIFY that a satisfactory standard certificate of death
filed with rile BEFORE the. burial or transit permit was issued:
1 'Ll
if Health or? other)
(Date of Issue of Permit)
h or? other) /
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE No.V*.3JQ, 1.942
DATE OF DISCHARGE F $ t>.« 1 3. >19.4.6.
RANK, RATING Staf
ORGANIZATION AND OUTFIT IT.,... £.,... Army....
SERVICE NUMBER 3.1.233...3.72...
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.
FORM R-301
filed for burial permit
h Board of Health
or its Agent.
INSTRUCTIONS
FOR
ICAl CERTIFICATE
INT OR TYPE
SE OR CAUSES
OF DEATH
do not enter
nore than one
ause for each
(a), (b) and (c)
'is does not mean
! mode of dying,
: as heart failure,
‘ nia, etc. It means
\disease, or compli-
I ns which caused
li.
I nditions, if any, 1
nich gave rise to f
i ove cause (a), r
. ting the under- l
i ng cause last. '
Conditions contrib- .
f to death but not
l id to the terminal
Ise condition given
F).
l-12.62-931t.553
\< Suffolk
lu
lO (County)
/u.
\o
<z/
v
& w
©tjf (Hmnmnttuiraltlj ox
KEVIN H. WHITE
M
"\V-
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
iWINTHROB
(City or Town making this return)
23
STANDARD
g-TttatfcglStesj CERTIFICATE OF DEATH Registered No
No Wlnthrop ConKmlty Hospital s,.
PHYSICIAN — IMPORTANT
2 FULL NAME .Q8UESS I (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(if so spec
(a) Residence. No.... 1.8.8 Bellingham... Avenue st Revere
U. S. War Veteran, t.rt.T T
ify WAR) WW 1
(Usual place of abode)
(City or town and State)
Length of stay: In place of death years months.. lthays. In place of residenceA-2-years months days
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February 12,1967
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
..Dec. 12., 166 ™., to..I.e.b., 12., 19...6.7
I last saw hltll^live on Feb, 1.2, , 19Q.7, death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)C.arc.irboma....of.....3-iver ( Hepatoma.)..
Due To
(b)
Due To
(c)
siG^^FicANZ'Vi..:T'.C.f5X.3.tl.on.,,Q.f ....:2.bb.QF.inal .
CONDITIONS 8/0/1067
INTERVAL
BETWEEN
ONSET AND
DEATH
2 non-
Was autopsy performed? .I5.Q
What test confirmed diagnosis? Pat.ho.lD.g',7:....r.e.X!.or.t.».
5 Was disease or injury in any way related to occupation of deceased ?llO.
If so, specif;
D..
(Print or Type Name)
(Address) 2.7-.-.Be.nping.ton....S±....,Date...Ee.'h< 13. ^...6. 7
— - — = —
Holy Cross felden
Place of Burial or Cremation
DATE OF BURIAL ...2/15/6.7
(City or Town)
..19
FUNERAL DIRECTOR Arthur 8..# POXCella
ADDRESS
8 76 Winthrop Ave., Revere
Received and filed M.
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED Mo-p-rl
divorced1 iea
UNKNOWN
11 If married,
HUSBAND of
(or) WIFE of..
widowed, or divorced, __ .
Marguerite ^...Francis
(Give maiden name of wife in full)
(Husband’s name in full)
h*CE
6?v.
Months
19
Days
If under 24 hours
Hours Minutes
13 occupation. .^eacher
(Kind of work done during most of working life)
14 Industry
or Business.
School
15 Social Security No . _
16 birthplace (City) Wat erbury
(State or country)
Conn.
17 NAME OF
FATHER John
F.Cruess
18 BIRTHPLACE OF
FATHER (City)
(State or country)
New Hartford
Conn.
19 MAIDEN NAME
of mother Mary
Horan
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
Cambridge
Hass.
21 Informant Marguerite F.Cruess
(Address) 1.88 Bellingham Ave., Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death
^>jp*jB^filed wi^ burial or transit permit was issued:
ignatwe of Agent of Bovd of Health or other) . ,
t/ZiiiljLjL**' Sdf..
tion) (Date of Issue of Permit) ’
A TRUE COPY ATTI
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE ?/. .J.9/...l§,
DATE OF DISCHARGE 1.?/. 1.3/...1 §.
RANK, RATING Y.ate
ORGANIZATION AND OUTFIT .3 e.n.t . . .. .Tr.aiftl ng. . . .QqtP.S
SERVICE NUMBER .125.-. .7.69
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.
FORM R-302
1
2
O
«
M
2
04
W
H
2
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ft,
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f-
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£ ps
< H
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co ft)
D 2
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2 0,
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M 2
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^ £ £
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/M
I H
i2i Hampden
IQ
(County)
o Monson Mass.
(City or Town)
MONSON STATE HOSPITAL
®ljr (Eflmmmuu?altl| nf fflaHHarljuaFttn
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
.Monson.
(City or Town making this return)
COPY OF
CERTIFICATE OF DEATH
No..
3.o
f (If death occurred in a hospital or institution.
Registered No.
irred in a hosp
...St. ( give its NAME instead of street and number)
2 FULL NAME ^ * ) (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S. War Veteran,
so specify WAR,..
J(V
(if'
(a) Residence. No.... Win throp, Mass. St_.
(Usual place of abode)
Length of stay : In place of death. 3? ears.
..months
,2!
days. In place of residence.... 2^ears. 1 . months Vrfays.
1
(If nonresident, give city or town and State)
M
MEDICAL CERTIFICATE OF DEATH
31,ATE OF February }} 1 ?67
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
19 to 19
I last saw h...^Tive on .. Feb.. 13 19....6.7death is said to
have occurred on the date stated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Bronchopneumonia
(a)
Due To
(b)
Due To
(c)
OTHER •
SIGNIFICANT Epl 1 CpSY
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
1 weel; AGE. .6.7.. Years.. .2
61 yr
Was autopsy performed? .HO.
What test confirmed diagnosis? ...C.l.l.n.i.CcL. 1 findings
5 Was disease or injury in any way related to occupation of deceased? .IW<
If so, specify
, M. D.
(Signed) Geor ge M * . R ei s M . O .
.Mqo.sqo ...State. Hpspj^l 2/13 19 67
(Address)
6 Holy Cross Cam. Madden, Mass.
Place of Burial or Cremation (City or Town)
February 1.6 19....67
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
yincent J. M a zzare Ha
address ..971 Saratoga St. E.Boston. Hass
8 SEX
9 COLOR
10 SINGLE
(write the word)
Fema 1 e
Whi te
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Single
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)
Years...— Months.
10
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
none
(Kind of work done during most working life)
14 Industry
or Business:.
none
15 Social Security No..
16 BIRTHPLACE (City).
(State or country)
hast Boston , Mass.
17 NAME OF
father Frederick S. Adams
18 BIRTHPLACE OF
FATHER (City).... St. Johns
(state or country) Newfoundland
19 MAIDEN NAME
OF mother Elizabeth A. Dunn
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
East Boston
Ma§_Sj_
21 Informant Monson State Hospital Records
(Address)
A TRUE COPY
DATE FILED
City or Town where death occurred)
IM 1 5 1367
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
FEB 2 0 ’67 AW
WINThrop, MASS.
FORM R-301
be filed for burial permit
with Board of Health
or itt Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode of dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any, J
which gave rise to I
above cause (a), r
stating the under- l
lying cause last. J
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given
in (a).
, *>>
£ n> A
< Suffolk s:,\ *
JC (County) (>y«
t
..Mint.hr op \
(City or Town)
(Unmiiumuipaltl) nf fHaflaarijUBEttii
KEVIN H WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
iWINTHROE
(City or Town making this return)
31
Registered No.
No..
UN + v-rsi-s Cnmrmim' fir Ur-i Qrs-i + a 1 HIf death occurred in a hospital or institution,
. W inthrOp...UQ^ Hospital St. ( give Its NAME instead of Stre.
2 FULL NAME..
Phillip, Ashman
street and number)
PHYSICIAN — IMPORTANT
deceased a
War Veteran,
specify WAR) / I
J (Was
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) U. S.
I if so s.
2 Brirablecomb St. t Lynn, Mass, ,
(a) Permanent Residence. No -SMff HOUgO Nursing HOfee St. . MinthrOP !....MaSS,
Length of stay: In place of death years months.. 4 days. In place of residence^sSyears months days.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February
(Month)
16,
(Day)
1967
(Year)
■4 I HEREBY CERTIFY, That I attended deceased from
/C/Jc i9.4<r «o B£A /A 1 A?
I last saw h//Y^live on ,_19.i
have occurred on the date stated above, at ..
a
death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
h > rtf'
(b)e &4&MS1JL. 4*)> _ A/f.
fa <* Sc-c.'tiTM r( c /fcMtPP-
Due To
(c)
A 77/i
OTHER . „ , -
SIGNIFICANT /g/lW&ttf&CTTfflS
conditions ^
INTERVAL
BETWEEN
ONSET AND
DEATH
!ya
3-h»(S- -
JTW-
sryfij
Was autopsy performed? Mo
What test confirmed diagnosis? ..
5 Was disease or injury in any way related to occupation of deceased
If so, specify
(Signature)
(Address)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
Lid
ro
10 SINGLE (write the word)
MARRIED
WIDOWED i
DIVORCED
UNKNOWN
11 If marfied, widowed, or divorced, V» .
HUSBAND of Alt W
(Give maiden name of wife ifi full)
(or) WIFE of
(Husband’s name in full)
loiQoua)
Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation .
14 Industry
or Business:
( KinJol work done duri
during most of working life)
15 Social Security No.
77 cr>7 -e
16 BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
/?<;
18 BIRTHPLACE OF
FATHER (City)
(State or country)
«w
19 MAIDEN NAME
OF MOTHER
&£ S' 5 / b C
20 BIRTHPLACE OF
MOTHER (City)....
(State or country)
/WAX
I HEREBY CERTIFY that a satisfactory standard certificate of death
w/sJittdTwitfr me^BEFOpEythe burial or. transit permit was issued:
Signa&re/of Agent of Board of Heaith or cither) „
(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 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.
FORM R-301
filed for burial permit
h Board of Health
or its Agent.
INSTRUCTIONS
FOR
UCAL CERTIFICATE
I NT OR TYPE
SE OR CAUSES
OF DEATH
do not enter
nore than one
:ause for each
(a), (b) and (c)
i is does not mean
mode of dying,
as heart failure,
•nia, etc. It means
disease, or compli- p
ns which caused
It
mditions, if any, )
iich gave rise to I
ove cause la), r
i ting the under- l
ing cause last. '
Conditions conlrib- .
’ to death but not
ed to the terminal
se condition given
0.
‘1-9-63-93631*8
(i So Ma It.
(County)
(City or Town)
No
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
ERTIFICATE OF DEATH
(City orTown making this return)
32
Registered No.
death °c-cVILe<? in a hospital or institution,
►
2 FULL NAME
CO 1 1 1 <q hn C t Q h Ll)
K«ve its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
^ (Zl^. ,1 'A'iWt4e&c..p Mcl^S'.
(a) Permanent Residence. No. _
(Usual place of abode) sf (Citd or town and State)
Length of stay: In place of death ..‘^..years.'j ...months...^ ..days. In place of residence j /^years months days.
3 DATE OF 1 / &
DEATH f?.....*.
DICAL CERTIFICATE OF DEATH
/ ^
(Month)
(Day)
(Year)
~4 I HEREBY C EtR.T/I F Y^7That I attended deceased /rum
19 to /-j£JL..S.. .../...& y 19 w A
I last sad l/ii/^live on T..., 19j2./f death is said to
have occurred on the date stated above, at . ^.t.^/L.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a
INTERVAL
BETWEEN
ONSET AND
DEATH
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way r^fited to occupation of deceased 1
If so, specif
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
r^a)e
9 COLOR
Wh,te
10 SINGLE (write the word)
MARRIED
WIDOWED
W 1 17VJ V> C,u — j /•»
SSS Sraro lit
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12
AGE
//
ears. ' Months ... t ....Days
Occupation ..
(Kind of work done during most of working life)
If under 24 hours
Hours Minutes
14 Industry
or Business.
'Zrt-
15 Social Security No..
16 BIRTHPLACE (City).
(State or country I
Ta&<2
17 NAME OI
FATHER
18 BIRTHPLACE C
FATHER (City)
(State or country)
19 MAIDEN
OF MOTHER
)THER
20 BIRTHPLACE OF
MOTHER (City)...
(State or country)
21 Informant
(Addres
s) /$A. 4$^
I HEREBY CERTIFY that a satisfactory standard certificate of death
hs filed with Ae BEFORE the-burial or transit permit was issued:
TOt IE* CADV ITTFtt
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons), thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occu-
pation, the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation.— Precise statement of occupation is very impor-
tant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Chil-
dren not gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that <yf 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
o be filed for burial permit
with Board of Health
or ita Agent.
INSTRUCTIONS
FOR
MEDICAL CERTIFICATE ['
PRINT OR TYPE
CAUSE OR CAUSES
OF DEATH
do not enter
more than one
cause for each
of (a), (b) and (c)
This does not mean
the mode o) dying,
such as heart failure,
asthenia, etc. It means
the disease, or compli-
cations which caused
death.
Conditions, if any,
which gave rise to
above cause (a),
stating the under-
lying cause last.
S
rv>
$
0
Is*
J
Hi
\
1
Conditions contrib- ^
uting to death but not
related to the terminal
disease condition given <.
in (a).
n:
100M-9-65-941327
II sjlebujc^
"j-j (ZIIjp (Ernnmmiiuttiltlf nf fSaBsarljuaFttB
KEVIN H. WHITE
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town making this return)
[o U) IMJ U ft Of STANDARD
lSr«Tw SSpT CERTIFICATE OF DEATH No UM.
No CO. \lMI..b. \MP QmMUM ill ... tiP.lA. ffivW M IE inMeadhof Street* and^num^r)
■ — IMPORTANT
2 full name JQ£M.JSUJL). A.LJ&1. HL US t ' 'M /< W„ , .
eteran, l\ L A C.
WAR).. '
. . ) PHYSICIAN — IMPO
d£..L.&LI!/..j A.LlQ'3.. M- Cl iikj L«
deceased is a married, widowed or divorced woman, give also maiden name.) \ U. S. War Vete
V if so specify W
t Residence. No (?.. '7../. ... C.C.. Ef... C.B.. U../...CCC;.. Si
Length of stay: In place of death.. ..0... years., ^...months / days. In place of residence / ^ years months. days.
(a) Permanent Residence. No. <£ 71. So Men VILLAS.. S,. $OMtTR I//L.L-E , MkSS
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF ..B.CCfC...
DEATH
(Month)
(Day)
.././/..A *
(Year)
4 I HEREBY CERTIFY, That I attended deceased froi
il.^2 i9 .LJ........ ,o ,,..42
I last saw h£?fclive on fz...Q7%i. ‘...qITA-U.J, deathjs_saidj
have occurred on the date stated above, at . ./.JLr/? m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
1 ™wrT7r
$e 2 c.£./y..^..^..n.AE
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
\ pULMUYfHiy
INTERVAL
BETWEEN
ONSET AND
DEATH
s/aj-
/jxy
'Mr
TTo
Was autopsy performed? /.w.... ,CT. „
What test confirmed diagnosis?
ziyiii
5 Was disease or injury in any way related to occupation of decease
If so, specify
’tn-
(Signature) / . ... E. .JB. EZ. , M. D.
j/iyiLCM A.!....:.i4..^;/L.£r'....24..i2.
(Print or Type Name) , J , u- / 1
(Address) r.tl.ll. 19..Z
— i.y. / |
Gl IH.££MaK kM&T/ioJiSpM
Place of Burial or Cremation (City or Town)
DATE OF BURIAL E£B Ai „Q
7 NAME OF
FUNERAL DIRECTOR
ERA A C AS t/‘ &£° A A
A DDR ESS A B ..S.P.At
f Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
D otfBD
11 If married, widowed, or divorced
HUSBAND of
(or) WIFE of
, (Give maiden name of wife. in full)
Al EKl O S M.l m*
(Husband’s name in full)
AG F. ears Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation.
//( i sBw/BA
(Kind of work done during most of working life)
14 Industry
or Business:
Cua
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
/W t. 35~Ri ICK. >('K
C /\A AL)/' i
17 NAME OF
FATHER
fC RAM L-A&G L ti-
ll BIRTHPLACE OF
FATHER (City)
(State or country)
C A a A oA
19 MAIDEN NAME
OF MOTHER
J/\AL \i HELPli'i
20 BIRTHPLACE OF
MOTHER (City)..
(State or country)
CAA AC? A
21 Informant
(Add re
ELSiL A fOirl t<$ COAo^NUR)
£ 7/ SOME R> //E Sc HE
I HEREBY CERTIFY that a satisfactory standard certificate of death
was ftl^d with me BEFORE the^bUrialaar transit permit was issued:
/"*\ (Signature of Agent crKBoard MHe^ith or otjierj
(J.....L
(Official Designation) / (Date of Issue of Permit)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the
following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease un-
related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is
absent from home when the certificate ai 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
filed for burial permit
th Board of Health
or its Agent.
INSTRUCTIONS
FOR
IICAL CERTIFICATE
INT OR TYPE
SE OR CAUSES
OF DEATH
do not enter
more than one
:ause for each
(a), (b) and (c)
i is does not mean
mode of dying,
as heart failure,
;nia, etc. It means
disease, or compli- p
ms which caused
ft.
mditions, if any, )
Weft gave rise to f
ove cause (a), r
iting the unThe text goes on. The rest is in the file.