USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1942 > Part 81
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19
(Official Designation)
(Date of Issue of Permit)
MEDICAL CERTIFICATION
20. Date of Death: Month ___
June
Day 19th
Year 1942 hour
Minute 7 P.M.
21. I hereby certify that I attended the deceased from
June
19 42 To June 19 19 42
that I last anw h
im
alive on June 19 19 42
Duration
Immediate cause of death
occlusion
1 hr.
Due to Arteriosclerosis,.
coronary and general
5 yrs.
Due to X
Other conditions
(Include pregnancy within 3 months of death)
Major findings: of operations X
|Mother| Father |
1.1. Birthplace ? ? Vermont
Viae Telephone from Annie Ge Keang 16. informant's Signature
16 (a) Address
St.Petersburg, Fla
17. Burial, cremation or removal? Removal
(d) Did Injury occur in or about home. on farm, in industrial public place?
place. In
19. Flied
Local Registrar
State File N Registrar's N
251
1. PLACE OF DEATH:
(a) County
Pinellas
(b) Precinct
Precinct No.L.
(Write name, uot number)
(e) City or
Town
St.Petersburg
City or
Town No.
39-511
2 FU
(e) Length of stay: In hospital or Institution
At place of death 6 Months
(Specify whether years, months or days)
(a) Length of
1 PLACE OF DEATH 3 SEX 8 AGE (S 15 PARENTS 16 17 Infor (Addr information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state is very important. See instructions and extracts from the laws on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION Indu 10 or B N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of 14 3 200m-10-'39. No. 8427-d
..
13. Birthplace
Vermont
(Signature of Agent of Board of Health or other)
........ A RUTE COPY ATTEST. TTEST:
(Registrar)
and that death occurred on the date and hour stated above. Coronary
(If not in hospital or institution. write street uumber or location)
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 regis- tration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death ... Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died ; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been de- livered to such board, agent or clerk, as the case may be, a satisfac- tory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, 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 physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the pur- pose, shall upon application make the certificate required of the at- tending physician. If death is caused by violence, the medical exam- iner 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 he obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such a removal shall constitute a permit for such removal ; provided, that such body shall be returned to the town from which it was removed within thirty- six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the death certificate contains a recital, as required by section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registration. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter fur- nish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition.)
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.)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observ- ance 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 ill- ness 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 un- related 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 septice- mia), 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 occupa- tion, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Cause of death means the disease, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease causing death. As related causes, name earlier morbid con- ditions, if any, related to the principal cause and any important complication of the principal cause.
Statement of Occupation .- Precise statement of occupation is very important, 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 occupation had been given up or changed on account of the disease causing death, report the usual occupation prior to illness. If the deceased had retired from busi- ness, report the usual occupation prior to retirement. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
PENNSYLVANIA
State File No. 02144 Registrar's No.
1. PLACE OF DEATH:
2. USUAL RESIDENCE OF DECEASED:
(a) State
(b) County
(b) City or town
Churata
(If outside city or town limite, write RURAL)
(c) Name of hospital or institution: rucala com.
(If not in hospital or institution, write street number or location)
(d) Length of stay: In hospital or institution
In this community
years. months or days)
(Specify, whether
(e) If foreign born, how long in U. S. A .?
years.
3. (a) FULL NAME The aleth, 21. Karel 20
3. (b) If veteran,
name war
3. (c) Social Security No.
5. Color or
6. (a)Single, widowed, married,
4. Sex
race
A divorced
6. (6) Name cf husband or wife
6. (c) Age of husband or wife if
and that death occurred on the date and hour stated above.
Duration
alive .... years Immediate cause of death
7. Birth date of deceased vie . (Month)
18. 1895
(Day)
(Year)
8. AGE:
Years
0
Months
Days 1
hr.
min
9. Birthplace
10. Usual occupation
(City, town. or county)
(State or foreign country)
MOTHER FATHER
[12. Name
13. Birthplace (City. town, or county) (State or foreign country)
14. Maiden name
15. Birthplace
(City. town, or county)
(State or foreign,country)
16. (a) Informant's own signature de mand & beeris
(b) Address _. villes . it. "
17. (a) Julia (b) Date thereof. (Burial, cremation, or removal) (Month) /(Day) (Year)
Price, / /7 (0) Accident, suicide, or homicide (specify)
(c) Place; burial or cremation
4
(6) Date of occurrence
(c) Where did injury occur?
(City or town) (County)
(State)
18. (a) Signature of funeral director
(b) Address
place?
While at work? 1
(Specify type of place) (e) Means of injury
23. Signature
(M. D. or other)
Address
Date signed
8-6917
(Date received local registrar)
(Registrar's signature)
Due to 4
Due to
17.
Other conditions
PHYSICIAN
(Include pregnancy within 3 months of death)
Major findings: Of operations
Of autopsy
Underline the cause to which death should be charged sta- tistically.
21-22. If death was due to external causes, fill in the following:
.
19. (a)
State of
(a) County
(c) City or town
(If outside city or town limita, write RURAL)
(d) Street No. €
(If rural, give location)
20. Date of death: Month
MEDICAL CERTIFICATION
day
year
1942 hour
011
minute
45/
21.
I hereby certify that I attended the deceased from
19
-to
19
that I last saw h _____ alive on 19= ·
11. Industry or business
If less than one day
(d) Did injury occur in or about home, on farm, in industrial place, in public
U. S. GOVERNMENT PRINTING OFFICE 16-13493
ST OF COMMERCE OF THE CODELUB
Dout
1. Usual Residence of Deceased
a) Siete Massachusetts
(b) County
gly " Klathrop
(If Outside City er Town Limite, Witte Rural)
252 Shore Drive
(d) A.F.D. and Box No.
Clilsen of Foreign Country?
Yo Il Yes. Name et No / Country
Il Veteran Nome War
Social Security Number
MEDICAL CERTIFICATION
PERSONAL AND STATISTICAL PARTICULARS
Marital
C. Status (drcle)
W D.
12 Death .. Sapteubs Date et
1.42 Time 11130 M
-
2L I hereby certify that I attended the deceased who died on the above date. I last sa
W/Idid not see him alive
Duration
Primary Cause of ban Compound fracture of skull
Contributery Compound fracture of lox
2. Compound fracture of lost this
Date of Operation
Dontens : Clinical. Lab., Y lo (Chock)
Was Autopay Performed 1
31. Il desth was due to external violence please mewer the following questions :
September Dele el Occurrence2 1919
a) Accident, Suicide Memicide (Speelly)
Accident (ь)
Place of Obathan County, Quer ale
(0) Accident.
Where : Home, Farm,
Work ros
Mouns of Mxplane accident.
(·) Injury
Station Hospital, Army Air Des, Date Hyned
Physician's O. Address Hunter Bald, Savannah, 0%
Sept. 4. 1942.
Tom
11 lowe than 24 k.
8 M.21 D. 1927cm
anh P. O. Address
(a) Date .. 9-4-42
O. Address of
of Persen
Eva J. Righton
CERTIFICATE OF DEATH GEORGIA DEPARTMENT OF PUBLIC HEALTH
Stete Flie Ne
254
(d) Industry. Public Piace
11
M R-302
PLACE OF DEATH
Essex (County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Lynn
(City or town making return)s 5
Registered No
1311
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Herbert A. . AcLellan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
160 Brookfield Rd.
St.
Winthrop
(If nonresident, give city or town and state)
months
days.
In this community
yrs.
mos.
days.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH.
Dec. 15, 1942
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY . That I attended deceased from
July 20
42.
19.
:, to
Nov. 27,
19
I last saw h.L.m ..... alive on.
Nov. 27, 19 42 death is said
to have occurred on the date stated above, at.
5. A.
.m.
Daration
Immediate cause of death.
Cerebral hemorrhage
2 mos.
Due to
Arterio sclerosis
10 yrs.
Due to
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
Of autopsy
What test confirmed diagnosis ?
clinical
20 Was disease or injury in any way related to occupation of deceased ?
If so, specify
(Signed)
Joseph O. Ward
M. D.
(Address)
Saugus , Mas.s.
Date 2/15 19 42
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.
Woodlawn, Wellesley
(Cemetery)
Dec. 17,
(City or Town 2
19.
22 NAME OF
FUNERAL DIRECTOR
H. D. Bisbee & Son
ADDRESS
Saugus , Mas.s.
Received and filed
- Jan 27
19:43
(Registrar of City or Town where deceased resided)
+
1
Lynn
(City or Town)
No.
268 Fays Ave.
2 FULL NAME
(a) Residence. No ..
(Usual place of abode)
Length of stay: In hospital or institution ..
rest home
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE. 5 SINGLE
MARRIED
WIDOWED
or DIVORCED
M
5a If married, widowed, or divorceLillian A. Dow
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
7 IF STILLBORN, enter that fact here.
8
AGE .. 7.9
Years
Months.
Days
Usual
Grocer
9 Occupation:
Industry
Retired
10 or Business:
II Social Security No.
12 BIRTHPLACE (City)
(State or country)
New Brunswick
13 NAME OF
FATHER
Alexander Mclellan
14 BIRTHPLACE OF
FATHER (City)
PARENTS
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
New Brunswick
17
Informant
Spencer Mclellan
(Address)
56 Main St. Saugus
50m-10-'39. No. 8427-f
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
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)
New Brunswick
(write the word) Wid.
6 Age of husband or wife if alive. .Years
If less than I day
Hours
Minutes
15 MAIDEN NAME
OF MOTHER
Rebecca (not known)
Relation, if any
son
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
Jan. 6,
19
43
Date of.
Underline the cause to which death should be charged sta- tistically.
DATE OF BURIAL
(If U. S.
War Veteran,
specify WAR)
....
years
4
٠٠٠
RM R-302
Essex
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
(City or town making return)
1
(C'ity or Town)
No.
Danvers State Hospital
(If death occurred in a hospital or institution, St. give its NAME instead of street and number)
Georgia A. Shorey
(If deceased is a married, widowed or divorced woman, give also maiden name.)
38 Enfield Rd
(a) Residenos. No.
St.
Winthrop
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution.
(Before death)
(Specify whether)
years
months
5
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
That I attended deceased from
Dec ........ 16 ..... , 19 ....
4.2 to.
19 .. 4.2 ..
I last saw h ........ @r.alive on ......
De.c ...
21
19 .... 43death Is sald to
have occurred on the date stated above, at .......... LOA .. .. m.
Duration
Immediate oause of death
Generalized arteriosclerosis 5 yrs
Pernicious anenia
10|vrs
Chr: myocarditis 1 VF.
Due to.
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings :
Of operations
Date of
should be
charged sta-
tistically.
What test confirmed dlagnosis ?.
clinical
20 Was disease or injury in any way related to occupation of deceased ?. n.Q.
If so, specify.
Myer Asekoff
(Signed)
DSH
Date
1/29/43
D.
(Address)
21 "PLACE OF BURIAL,
Qak Hill Newburyport
DATE OF BURIAL
19
22 NAME OF
FUNERAL DIRECTOR . J. Mckenney
ADDRESS
Newburyport
Received and filed 19
(Registrar of City or Town where deceased resided)
50m (e)-1-41-4667
2 FULL NAME
3 SEX
femal e
8
82
Usual
9 Occupation :
Industry
10 or Business :
13 NAME OF
FATHER
PARENTS
Informant.
(Address)
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. 16, Sec. 12, G. L.)
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk
AGE
Years ...
4 COLOR OR RACEj
whi te
5 SINGLE
(write the word)
18 DATE OF
DEATH
Dec. 21, 1942
MARRIED
WIDOWED
OF DIVORCED Wido wed
5a If married, widowed, or divoroed HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of cannot belearned.
(Husband's name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
.....
Months.
Days
If less than 1 day Hours .Minutes Due to.
housewife
11 Social Security No ..
none
12 BIRTHPLACE (City)
(State or country)
Sandwich,
Jacob Roberts
14 BIRTHPLACE OF
FATHER (City)
New Hampshire
(State or country)
15 MAIDEN NAME
OF MOTHER
Roberta
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
New Hampshire
17 M.K.Mchillins ( .. Relation, if any
DSI
7
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
2/1/43
19
CREMATION OR REMOVAL
(Cepeber23/42
(City or Town)
Underline the cause to which death
Of autopsy
PLACE OF DEATH
Dan fonts
Registered No.
250
(If U. S.
speolfy WAR)
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