USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1942 > Part 69
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SPACE FOR ADDITIONAL INFORMATION
A R-303A
PLACE OF DEATH Sullink (County) ManThrob (City or Town)
....
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No
S (If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Storestille
no. Carolina
(If nonresident, give city or town and state)
years
months
days.
In this community
yrs. 2 mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE
(write the word)
MARRIED
WIDOWED
OF DIVORCED engle
Sa If married, widowed, or divorced HUSBAND of.
(Give maiden name of wife in full)
(Husband's name in full)
.years
7 IF STILLBORN, enter that fact here.
AGE : 24 Years Months. Days
If less than 1 day .. Hours .......... ... Minutes
Usual
9 Occupation:
U.S. army
11 Social Security No ..
12 BIRTHPLACE (City)et
(State or country) north Car
13 NAME OF
FATHER
William E. Youben.
14 BIRTHPLACE OF
FATHER (City) ...
(State or country)
15 MAIDEN NAME
OF MOTHER
Martha
18 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Relation, if any
Informar
U.S. Gramy Records (at Banks)
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE theburial or transit permit was issued: Nm. D. (buldrer (Signature of Ageht of Board of Health or other)
Health Officer 11/2/42
(Official Designation) (Date of Issue of Permits
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
Oct- 31-1942
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are
as follows: (If an injury was involved, state fully.) Traumatic Intracraneal Hemorrhage Fractured Stall
20 Accident, suicide, or homicide, (specify) acudentel
Date of occurre
October -31
.196.4.2
Where did
Injury occur?
Besten
(City or Town and State)
Did injury occur in or about home, on farm, in industrial place, in public place? army laze
(Specify type of place)
Manner of
Injury
Fell accidentally at army
Nature of
Base So. Dertien Q +31-1949
Injury ....
While at work ?.
1
Was there an autopsy ?.
21 Was disease or injury in any way related to occupation of deceased? 7
If so, specify
2
(Signed)
Tunik buckles THEM.D.
(Address)
3 Atin
lose-1- 1962
22 Madison north Carolina
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
nov. 5
19.
23 NAME OF
FUNERAL DIRECTORULm+ vue
ADDRESS 254 Beady
19
Received and filed
(Registrar)
25m-2-'40-D-729-b
1 (or) WIFE of. 8 PARENTS 17 of Death. See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classificd under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of Industry 10 or Business:
Inst Buks Hospital No ... William 1. Forbes 2 FULL NAME
(a) Residence. No .....
(Usual place of abode)
Length of stay: In hospital or institution
(Specify whether)
(If U. S. War Veteran, specify WAR)
1
6 Age of husband or wife if alive.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he dled, defined as required by sectlon one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death . . . Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to Issue such permits, or If there Is no such board. from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiv- Ing tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesald or from the clerk of the town where the body Is buried. No such permit shall be Issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement contalning the facts required by law to be returned and recorded, which shall be accompanled, in case of an original Interment, by a satisfactory certificate of the attending physician, If any, as required by law, or In lieu thereof a certificate as hereinafter provided. If there Is no attending physiclan, or if, for sufficlent reasons. his certificate cannot be obtained early enough for the purpose, or Is In- sufficient, a physician who Is a member of the board of health, or em- ployed by It or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by vlolence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and In the possession of the undertaker deslring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which It was removed within thirty-six hours after such removal, unless a permit in the usual form for the re- moval of such body has been sooner obtained hereunder. If the death certificate contains a recital, as required by section ten of chapter forty- six, that the deceased served in the army, navy or marine corps of the United States In any war In which It has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit It to the clerk of the town for registration. The person to whom the permit Is so given and the physiclan certifying the cause of death shall thereafter furnish for registration any other necessary Information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chop. 114, Sec. 45. G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or Its agent appointed to issue such permits, or If there is no such board, from the clerk of the town where the body is to be buried or the funeral Is to be held, or from a person appointed to have the care of the cemetery or burial ground In which the Interment Is made. . . . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence. If a medical examiner has notice that there is within his county the body of such a person, he shall forthwith go to the place where the body lies and take charge of the same; . .. - General Laws, Chap. 38, Sec. 6.
. . He shall in all cases certify to the town-clerk or registrar in the place where the deceased died his name and residence, if known; other- wise a description as full as may be, with the cause and manner of death. -General Laws, Chap. 38, Sec. 7.
. The medical examiner certifies the cause and manner of death to the best of his knowledge and belief.
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 unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only au those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician Is absent from home when the certificate of death is needed.
(3) Medical Examiners will Investigate and certify to all deaths supposably due to Injury. These include not only deaths caused directly or Indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deathe of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause, the nature of an injury and of its consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway accident." "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." "Fracture of the skull with asso- ciated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause, its known or presumable nature; and (2) under manner, indicate the cir- cumstances 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.)"
DESCRIPTION (for unknown person).
1
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have met his death by violence, until a permit, signed by the Medical Examiner, has first been obtained .- General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
M R-305
3 SEX female AGE Industry 10 or Business: PARENTS 25m-10-'39. No. 8427-g after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided as soon as possible 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 (State or country)
PLACE OF DEATH
Essex
(County)
Danvers
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Denvers (City or town making return)
212
Registered No.
1 (If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME
Sybil Jenks
(If deceased is a married, widowed or divorced woman, give also maiden name.)
145 Washington
St.
Winthrop
(a) Residence. No .....
(Usual place of abode)
Length of stay: In hospital or institution.
years
months
8 days.
(If nonresident, give city or town and state)
In this community
yrs.
mos.
days.
(Specify whether)
MEDICAL CERTIFICATE OF DEATH
19 DATE OF
DEATH
Sep. 27, 1942
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : (If an injury was involved, state fully.)
Pulmonary embolism
20 Accident, suicide, or homicide (specify).
Date of occurrence. Where did Injury occur?
19
(City or town and State)
Did injury occur in or about the home, on farm, in industrial place, or in public place ?
Mannor of
Injury
Nature of
Injury
While at work?
Was there an autopsy ?.
......
ves
21 Was disease or injury In any way related to cccupation of deceased ?.
no
If so, specify
J
.
W. P. Murphy
(Signed)
M. D.
(Address)
Peabody.
90GB8/42 19
22 Lebanon W. Lebanon NH
Place of Burial, Cremation or, Remoyal.
(City or Town)
Informant
(Address)
17
M.K .McPhillips
DiSII
4
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
10/21/42
19
(write the word)
divorced
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of cannot be learned
(Husband's name in full)
6 Age of husband or wife@talivao.t be learned .years 7 IF STILLBORN, enter that fact hero.
8 42 Years Months. Days
If less than I day
Hours
Minutes
Usual
9 Occupation:
housework
Il Social Security No ..
icannot be learned
12 BIRTHPLACE (City)
Concord
13 NAME OF
FATHER
Elisha Skurtleff
14 BIRTHPLACE OF
FATHER (City)
Bridgewater
(State or country)
vt.
15 MAIDEN NAME
OF MOTHER
Woods
16 BIRTHPLACE OF
MOTHER (City)
Hartford,
(State or country)
Vt.
Relation, if any
DATE OF BURIAL
9/29/42
19
23 NAME OF
FUNERAL DIRECTOR
Richard H. White
ADDRESS
Winthrop
Received and filed 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
white
Danvers State Hospital No
(If U. S.
War Veteran.
specify WAR)
1
(Specify type of place)
M R-302
PLACE OF DEATH
fifaunty)
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
DASTON ... (City or town making zettrs Registered No. .. $862
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Edward S binney
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(If U. S.
War Veteran,
World War 1
specify WAR)
(a) Residence. No .......
36 Bellevue AVA
...........
......
St.
winthrop
(Usual piace of abode)
Length of stay: In hospital or institution.
(Specify whether)
.... years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Oct
6
1942
(Month)
(Day)
(Year)
Uct
19
19, I HEREBY CERTIFY
That f attended deceased from
6
42
I last saw h.j.m .... alive on.
Oct 6
19 ........ , 2death is said
to have occurred on the date stated above, at.
8.56P
m.
Daration
Immediate cause of death ....
Terminal pneumonia
days
.....
Due to
Pulmonary embolism
Pulmonary edena
Due to .
.Hypertension
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Underline
the cause to
which death
should be
charged sta-
tistically.
What test confirmed diagnosis ?.
20 Was disease or Injury In any way related to eccepation of deceased ?
If so, specify
(Signed).
A Reid Johnson
M. D.
(Address) ........ Bo.s.ton .... Ma.s.s.
Data DOct: 942
21 PLACE OF BURIAL.
Relation, if any
(brother
.ix
CREMATION OR REMOVAL-
Mit Auburn
Cambridge
DATE OF BURIAL
(Cemetery)
Oct ¿City or Town)
¥22
19
22 NAME OF
FUNERAL DIRECTOR
Joseph H Rockett
ADDRESS.
Mass Ave
Cambridge
Received and filed
Det I-
19 .- 42
(Registrar of City or Town where deceased resided)
-
3 SEX
M
4 COLOR OR RACE 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive.
7 IF STILLBORN, enter that fact here.
0
AGE 49 Years
Months.
Days
Usual
9 Occupation:
Insurance Agent
Industry
John Hancock Inc
10 or Business:
II Social Security No.
012-09-7302
12 BIRTHPLACE (City)
Somervillevass
(State or country)
13 NAME OF
FATHER
Edwar V Binney
14 BIRTHPLACE OF
FATHER (City)
Somerville
15 MAIDEN NAME
OF MOTHER
Sarah Smith
16 BIRTHPLACE OF
MOTHER (City)
New York
(State or country)
17
Informant.
(Address)
Wilshire Winthrop
Walter Rowe
50m-10-'39. No. 8427-f
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.)
PARENTS
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
(State or country)
Mass
(write the word)
Married
Florence R Benney
(Give maiden name of wife in full)
4.9
years
lf less than 1 day
Hours
Minutes
A TRUE COPY.
F.TTEST:
(Registrar of city or towy where death occurred)
DATE FILED a0ct.13
.. 19 ..
42
$
No ...... .Mass .... Osteopathic ..... Hospital
St. l
(If nonresident, give city or town and state)
... ,
to.
19.
Of autopsy
Date of.
Law
RM R-302
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.) resided in another city or town at the time of death should be msde forthwith and transmitted on Form R-302 to the clerk
PLACE OF DEATH
Suffolk
(County)
Revere
(City or Town)
218 Beach
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Revere (City or town making return) 204
Registered No.
(If death occurred in a hospital or institution, St. give its NAME instead of street and number)
2 FULL NAME
Catherine Daily ( Hayde)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
96 Loring Rd.
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In hospital or institution.
(Before death)
(Specify whether)
years
months
days.
In this community
18yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE|
White
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
5a If married, widowed, or divoroed
HUSBAND of
(or) WIFE of
Charles
... A.
(Husband's name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
8
AGE 84
Years
Months.
Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation :
Housewife
Industry
10 or Business:
At home
Il Social Security No. None
12 BIRTHPLACE (City)
(State or country)
Ireland
13 NAME OF
FATHER
Edmund Hayde
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
15 MAIDEN NAME
OF MOTHER
Mary Burns
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Charles Daily
if any
Relatiound
(Address) 15 Birch Rd. Winthrop, Mass.
Informant.
ATTEST:
A TRUE COPY. Fr. Deta M. Disnos (Registrar of city or town where death occurred) October 20, 42 19 DATE FILED
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
October
6,
1942
(Month)
(Day)
(Year)
19 ' HEREBY
October
3
19
to
I last saw h ........... alive on.
October 6 1942, death is said to
have occurred on the date stated above, at
7:15 P.
.m.
Duration
Immediate cause of death
Broncho-pneumonia
10/5/42
Due to
Cerebral Hemorrhage
10/3/42
Due to.
Arteriosclerotic Heart
Disease
Jan. 1942
Other conditions
None
(Include pregnancy within 3 months of death)
Physician
Major findings :
Of operations.
None
Date of
should be charged sta- tistically.
Of autopsy.
None
What test confirmed diagnosis ?.
20 Was disease or injury in any way related to ocoupation of deceased ?.
NO
If so, specify.
Morris I. Sacks
(Signed)
M. D.
(Address)
45 Shirley Ave. Date 10/6 1942
21 PLACE OF BURIAL,
Holy Hood
Brookline
DATE OF BURIAL
Lober
22 NAME OF
FUNERAL DIRECTOR
Michael J. Porcella
ADDRESS
10 No . Bennet
"St. , Boston
Received and filed
.19
(Registrar of City or Town where deceased resided)
50m (e)-1-41-4667
1
No.
(If U. S.
War Veteran,
specify WAR)
(Usual place of abode)
None
( Give maiden name of wife in full)
CERTIFY,
42
October 6,
1942
That I attended deoeased from
Underline the cause to which death
CREMATION OR REMOVAL
metery) 9,
(City or Town)
19
12
M R-302
50m-10-'39. No. 8427-f Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the tinie PARENTS after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) 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
Suffolk
PLACE OF DEATH
(County) Boston
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON (Clty or town making return
Registered No.
8868
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Tillie Stone
(If deceased is a married. widowed or divorced woman, give also maiden name.)
79 Shore Drive
St.
Winthrop
(If nonresident, give city or, town and state)
In this community & yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
F
4 COLOR OR RACE 5 SINGLE
MARRIED
VÝ
WIDOWED
or DIVORCED
(write the word)
Widow
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Louis ..... Stone
(Husband's name in full)
.years
6 Age of husband or wife if alive. 7 IF STILLBORN, enter that fact horo.
8 AGE 92 Years
Months
Days
If less than 1 day Hours
Minutes
Usual
9 Occupation:
Housework
Industry
At home
Id or Business:
11 Social Security No.
None
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Israel Dunsky
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Leah
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17 Home Records
Relation, if any .No.ne.
(Address) 21 Queen St Dorchester
A TRUE COPE
ATTESTI
(Registrar of city or towy where death occurred)
DATE FILED Oct 13 19 42
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
Oct
7
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY.
Oct 4
19.
42
That I attended deceased from
19.42
I last saw h Or alive on.
Oct 7
to have occurred on the date stated above, at.
2
P.
m.
.....
19
42 death is said
Immediate cause of death ....
Bronchopneumonia
....
Due to
Gastric
CanGenoma
Due to Arterio Sclerosis
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Of autopsy
What test confirmed diagnosis ?
20 Was disease or Injury In any way related to occupation of deceased ?
If so, specify.
(Signed)
B A Udelson
M. D.
(Address) ..
Date.0.0.1 ........ 79.4.2
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Chevra Thilim W Rox
DATE OF BURIAL
(Cemetery)
(City or Town)
Oct 8
19
22 NAME OF
FUNERAL DIRECTOR Manuel Stanetsky
ADDRESS
10 Washington
Dorchester
Received and Bled ..
19
48
(Registrar of City or Town where deceased resided)
y
(a) Residence. No ...
(Usual place of abode)
Length of stay: In hospital or institution ..
(Specify whether)
2 years
3 months
days.
....
(If U. S.
War Veteran,
specify WAR)
NO
1942
oct
7
to.
Duration
Underline the cause to which death should be charged sta- tistically.
Date of ..
Informant
84am
No .. Hebrew ... Ladies ... Homo .... for ... Aged ...
.......... St. (
٠٥
..
A R-302
PLACE OF DEATH
Middlesex (County)
Cambridge (City or Town)
No Cambridge City Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Cambridge (City or town making return)
06
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Baby Boy Campbell
(If deceased is a married, widowed or divorced woman, give also maiden name.)
283 Court Road
.St.
Winthrop, Mass.
(If nonresident, give city or town and state)
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
October
1942
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY.
That I attended deceased from
I last saw h ............ alive on.
19.
death is said
to have occurred on the date stated above, at.
.. m.
Immediate cause of death.
Duration
6 Age of husband or wife if alive ..
Stillborn
years
If less than 1 day Hours Minutes
Premature Stillborn
Due to
Cord around neck
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Of autopsy ... no
What test confirmed diagnosis ?.
Clinical
20 Was disease or Injury In any way related to occocation of deceased ? no
If so, specify
(Signed)
P ...... McGown
M. D.
(Address)
Cambridge, Mass. Date
10/197
42
21 PLACE OF BURIAL.
CREMATION OR REMOVAL Holy Cross - Malden
(Cemetery)
(City er Town)
DATE OF BURIAL
October 10 1942
19
22 NAME OF
FUNERAL DIRECTOR
Charles H. Treanor
ADDRESS
Last Boston, Mass.
Received and filed
6
19
(Registrar of City or Town where deceased resided)
3 SEX
Male
4 COLOR OR RACE: 5 SINGLE
MARRIED
White
WIDOWED
or DIVORCED
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Husband's name in full)
7 IF STILLBORN, enter that fact here.
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