USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1943 > Part 74
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6. (a)Single, widowed, married
divorced
Widowed
that I last saw h.
alive on
19
and that death occurred on the date and hour stated above.
years
Immedlate cause of death
natural causes
7. Birth date of deceased
July
(Month)
(Day) (Year)
8. AGE:
Years 62
Months
Days
If less than one day
hr.
min
9. Birthplace
Provincetown
Mass
10. Usual occupation
Retired __ (Merchant)
11. Industry or business
Other conditions (Indude pregnancy within 3 months of death)
PHYSICIAN
12. Name
13. Birthplace (City. town, or county) (State or foreign country)
14. Maiden name
Of operations
15. Birthplace
(City. town, or county) (State or foreign country)
16. (a) Informant's own signature ... Ma88. Charles __ C.Gray(R .W.W.
22. If death was due to external causes, fill in the following:
17. (a) Burial
(b) Date thereof.
Aug .__ 8 ___ 1945| (a) Accident, suicide, or homicide (specify)
(Month), (Day) (Year)
(c) Place; burial xxwwwdixWinthrop Cen.,Winthrop, MEBDate of occurrence
(c) Where did injury occur?
(City or town) (County) (Stato)
(+) Did injury occur in or about home, on farm, in industrial place, in public place?
(Specify type of placo)
While at work? (e) Means of injury
123. Signature
Leon u. Orton
(M. D. or other) M.D.
(Date received- registraf)
Date signed
Aug. 5.
8-8217
U. S. GOVERNMENT PRINTING OFFICE 16-13463 OCT 27 1943
1943
Duration unknown
Due to
Due to
(State or foreign country)
MOTHER FATHER
Mejor findings:
Of autopsy one done
Underline the cause to which death should be charged sta- tistically.
18. (a) Signature of funeral director Richard W. Walton
Bristol
(b) Address
19. (a) Aug. 8.194)3
Myra -- K,EmmonA .;
Ashland, N.H.
Address
3. (b) If veteran,
name war
3. (c) Social Security No.
case
19
., to
19
6. (b) Name of husband or wife
6. (c) Age of husband or wife if
alive
4
1881
1
(b) Address. Winthrop,
(Burial, cremation, or removal)
(If outside city or town limits, write RURAL)
(c) Name of hospital or institution:
(If not in hospital or institution, write streot number or location)
RM R-302
Middlesex
The Commonturalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Cambridge. (City or town making return)
214
(If death occurred in a hospital or institution, St.
give its NAME instead of street and number)
2 FULL NAME
Edwin Antunes
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
45 Read Street
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
3
months
24ays.
In this community 30
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Aug 19
1945
(Month)
(Day)
(Year)
5a If married, widowed, or divoroed
HUSBAND of
Ethel.
... Vance
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive 50
years
7 IF STILLBORN, enter that fact here.
8
AGE.
5.6 Years.
Months.
Days
If less than 1 day
.Hours .......
Minutes
Usual
9 Occupation :
Printer
Industry 10 or Business :
11 Social Security No. 028-05-3214
12 BIRTHPLACE (City)
(State or country)
Portugal
13 NAME OF
Jessie Antunes
FATHER
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Portugal
(State or country)
Marie Antunes
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
Portugal
(State or country)
Ethel Antunes
wi fo
17
Informant
45 Road .St.
( Address)
A TRUE COPY.
Aug 21, 1943
ATTEST :
(Registrar of city or town where death occurred)
DATE FILED
frederick At war
22 NAME OF
FUNERAL DIRECTOR
John F O Maley
ADDRESS
Winthrop Magg
Reoelved and filed.
001-1-1943
19
(Registrar of City or Town where deceased resided)
.....
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.) resitled In another city or town at the time of death should he made forthwith and transmitted on Form R-302 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
1
PLACE OF DEATH
(County) Cambridge
(City or Town)
No. Holy Ghost Hoepital
........
3 SEX
4 COLOR OR RACE|
5 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
19 | HEREBY CERTIFY,
That I attended deceased from
Aug 1
1943 .... ,
toAng ..... 2.9
I last saw h ...... i.m ... alive on ..
Aug 18, 193, death Is said to
have occurred on the date stated above, at.8 ..... 26
... m.
Duration
Immediate cause of death .... Carcinoma ..... of .. Base of tongue
c metastas68
to neck
Sept
1942
Due to
Due to.
Other conditions
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of
Physician Underline the cause to which death should be charged sta- tistically.
Of autopsy What test confirmed dlagnosis?
20 Was disease or injury In any way related to oooupatlon of deqpeed ?.
If so, speolfy
(Signed) Georg.6 ......... Connor.
M. D.
(Address) 9.22MasTe ...
Date ..... 4.11 ..... 199 .... 4.3
21 PLACEion BE
CREMATION UR REMOVAEm. Winthrop.
Au (CemetTry) 1943
(City or Town)
DATE OF BURIAL
19
50m (e)-1-41-4667
Relation, if any
Registered No.
1.27
(If U. S.
War Veteran,
specify WAR)
M
ORM R-302
Suffolk
The Commonturalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Chelsea
(City or town making return)
Registered No.
586
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Francis J.Rogers
2 FULL NAME
(If deceased is a married, widowed or divorced
woman, give also maiden name.)
56 Sargent
(a) Residenoe. No.
(Usual place of abode)
hospital
7
(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
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE!
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
5a If married, widowed, Jor divorcedS . Sullivan
HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if alive 49
years
7 IF STILLBORN, enter that fact here.
55
2
15
8
AGE
Years.
Months.
.. Days
If less than 1 day
Hours.
.. Minutes
Supervisor
Usual
9 Oocupation :
U. S. Government
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
¥chtel
13 NAME OF
FATHER
14 BIRTHPLACE OF
Billerica, Mass.
FATHER (City)
(State or country)
bridget Gavin
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or countyharital Records
Relation, if any
A TRUE COPY.
ATTEST:
(Registrar of city or, town where death occurred)
DATE FILED
9./14/43
19
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
79 Atlantic St.Winthrop
Reoelved and filed OCT 1 , 1943
.19
(Registrar of City or Town where deceased resided)
50m (e)-1-41-4667
3 SEX M (or) WIFE of PARENTS 17 Informant (Address) 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 made forthwith and transmitted on Form R-802 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD Industry 10 or Business :
PLACE OF DEATH
1
(City or Town) Soldiers' Home Hospital No.
St.
Winthrd
(If U. S.
War Veteran,
specify WAR)
World 1
St.
Sept . 14, 1943
(Month)
(Day)
(Year)
19 | HEREBY, CERTIFY,
That I attended deoeased, from
19
to .. Sept . 14 43
19.
I last saw h.
.. alive on
have oocurred on the date stated above, at
Duration
Immediate cause of death bogis
not
....
known.
Due to.
Due to.
Hypertensive heart
ot
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings :
Of operations
Date
of ...
should be
Laboratory charged sta-
tistically.
What test confirmed diagnosis ?
20 Was disease or Injury in any way related to oooupatlon of deceased ?.
If so, speolfy ..
Timothy F.Pogan
(Signed)
Soldiers' Home
9.1.14., M. 6.3
(Address)$.y
+1 Pate ..........
19
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Sort. 17, 1043
(City or Town)
DATE OF BURIAL
(Cemeter})
J. F. O.P. Long
19
Underline the cause to which death
disease
known
Of autopsy
Ireland
18 DATE OF
DEATH
Sept. 14
7:15 A:
m.
death Is sald to
Suffolkx
The Commontucatth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
S
( If death occurred in a hospital or institution,
St.
{ give its NAME instead of street and number)
Samuel Shapiro
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No.
(Usual place of abode)
49 Sagamore Ave.
St.
winthrop
Mass.
(If nonresident, give city or town and State)
Length of stay: In hospital or institution.
( Before death)
( Specify whether)
years
months
1 __ days.
In this community
yrs.
mos.
14
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
September
15
(Month)
(Day)
( Year)
19 | HEREBY CERTIFY,
That I attended deceased from
Sept ..
1
19
43
to
Sept. 1519.
43
I last saw h.
im
.. alive on
Sent. 15 19 413 death Is said to
have occurred on the date stated above, at 9.25 p. m.
Duration
Immediate oause of death
Carcinoma of rectum
mos
Due to
Due to. Hypertensive and
Ician Arterioscleroticheart disease yrs. Other conditions. (Include pregnancy within 3 months of death)
Major findings :
carcinoma of rectum
Of operations
Date
of 9/1/1/43
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 oocupation of deceased?IO
If so, specify.
(Signed)
R. R. Shapiro
M., D.
(Address)
B.I. Hospital
Date
9/1519 43
21 PLACE OF BURIAL, Puritan Cem.
Woburn Mass,
CREMATION OR REMOVAL
(Cemetery)
(City or Town)
DATE OF BURIAL
Sept. 16 19%
22 NAME OF
FUNERAL DIRECTOR
M ....... Stanetsky.
ADDRESS
Boston
19
(Registrar of City or Town where deceased resided)
MARGIN RESERVED FOR BINDING
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased WRITE PLAINLY, WITH UNFADING BLACK INK - of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
PLACE OF DEATH
(County) Roston
1
(City or Town)
No.
Beth Israel Hospital
BOSTON (City or town making return)
Registered No.
845316
THIS IS A PERMANENT RECORD
50m (e)-1-41-4667
4 COLOR OR RACE
5 SINGLE
(write the word)
MARRIED
WIDOWED Widowed
or DIVORCED
5a If married, widowed, or divorced HUSBAND of
Mary Blender
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
AGE 75 .Years .. Months. Days
If less than 1 day
Hours
Minutes
Usual
Dry Goods Store Prop.
Industry 10 or Business :
11 Social Security No ..
none
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Isaac H. Shapiro
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Ada
-
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17
Informant
Celia Berger
D'avanter (Address)
A TRUE COPY.
Francis
8. Jan
ATTEST :
(Registrar of city or town where death occurredy.
DATE FILED
Sept. 20
19
43
same
Of autopsy
9 Occupation :
(Give maiden name of wife in full)
FORM R-302
3 SEX
M
1943
Received and filed
OGT-13-1313
ORM R-302
Essex
(County)
Danvers
(City or Town)
No. Danvers State Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
(City or town making return)
Registered No.
217
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
William P. Natale
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
114 Pleasant
WWinthrop
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution
(Before death)
(Specify whether)
years
1
months
20days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
white
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
married
5a If married, widowed, or divorced
HUSBAND of
Clara ... R ....... Moody.
(Give maiden name of wife iu full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive 8.3
years
7 IF STILLBORN, enter that fact here.
8
AGE
Years.
.. Months.
Days
If less than 1 day
Hours .........
.. Minutes
Usual
Retired Real Estate Dealer
11 Social Security No.
cannot be learned
12 BIRTHPLACE (City)
Cambridge
John Peter Natale
14 BIRTHPLACE OF
FATHER (City)
(State or country)
"Italy
15 MAIDEN NAME
OF MOTHER
Emma Burns
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
M.KaMcPhillips
DSH
Relation, if any
A TRUE COPY
ATTEST :
(Registrar of city or town where death occurred)
DATE FILED 9/27/43
19
18 DATE OF
DEATH
Sep. 17, 1943
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
July
28
That I attended deceased from
19
4,3 to.
Sep ...
17
1943
alive on
I last saw h
im
Sep.
17,, 19 43
death Is sald to
have ocourred on the date stated above, at.
10 .... 15A .... m.
Duration
Immediate cause of death
Arteriosclerotic heart disease3yrs
Due to.
Due to.
Other conditions
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of
should be charged sta- tistically.
Of autopsy
What test confirmed diagnosisclinical
20 Was disease or Injury in any way related to oooupatlon of deceased ?.
If so, speolfy
(Signed) Abraham .... Gardner
M. D.
(Address)
DSH
D 2/23/199
21 PLACE OF BURIAL,
Winthrop Winthrop
CREMATION OR
(City or Town)
DATE OF BURIAL
9/20/43
19
22 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS
Winthrop
Received and filed OCT 15 1943 19
(Reglatrar of City or Town where deceased resIded)
50m (e)-1-41-4667
1
PLACE OF DEATH
St.
(If U. S.
War Veteran,
specify WAR)
(Usual place of abode)
2 FULL NAME
3 SEX
male
83
9 Occupation :
Industry
10 or Business:
13 NAME OF
FATHER
PARENTS
17
Informant
(Address)
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
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 made forthwith and transmitted on Form R-302 to the clerk
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
(State or country)
Physician Underline the cause to which death
بسبب
سبيبـ
RM R-302
Middlesex (County)
Tewksbury
(City or Town)
No. Tewksbury State Hospital and Infirmary
The Commonturalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
IEWASDURI SIATE HOSPITAL and INFIRMARY TEWKSBURY, MASSACHUSETTS (City or town making return)
Registered No. 352 18 ..
S (If death occurred in a hospital or institution, St. give its NAME instead of street and number)
2 FULL NAME
George
.. Boutin
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
225 River Road
ŚŁ
Winthrop
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution.
(Before death)
(Specify whether)
3
years LO months
16 days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Ilale
4 COLOR OR RACE|
Thite
5 SINGLE
(write the word)
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 years
7 IF STILLBORN, enter that fact here.
8
AGE
41
Years
9
25
If less than 1 day
Hours.
Minutes
Usual
9 Occupation :
Rigrer
Industry 10 or Business :
11 Social Security No ..
12 BIRTHPLACE (City)
inthron
(State or country)
Tras's
13 NAME OF
FATHER
Gerard Boutin
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Not learned
(State or country)
Canada
15 MAIDEN NAME
OF MOTHER
Ella La Voix
16 BIRTHPLACE OF
C'elsea
MOTHER (City)
(State or country)
17
Informant
(Address)
Hospital Records
Relation, If any
A TRUE COPY.
ATTEST:
C. Winthings Houghton mSupt.
(Registrar of city or town where death occurred)
DATE FILED
Couto ber 20
..... 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
September
19
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
NOV.
3
19.
39
Sept. 10
to
19
43
I last saw h ........ j.m.alive on ....
1.0 ...... , 19 .... 4.3death Is said to
have occurred on the date stated above, at ....
10:45 ... 2m.
Duration
Immediate cause of death Multiple Sclerosis
6 VRS
Due to.
Due to.
Other conditions
Cystitis ; Trophic Ulcers
Physician
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of
Underline the cause to which death should be charged sta- tistically.
Of autopsy
What test confirmed diagnosis ?.
Clinical
20 Was disease or injury In any way related to oocupatlon of deceased ?......... O
If so, speolfy.
(Signed)
Kurt C. Lessy
M. D.
(Address)
T. S. H. & I., Tewksbury
Date ..
9-20943
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Holy Cross ...
aldon
(Cemetery)
(City or Town)
DATE OF BURIAL
September 23
19
22 NAME OF
FUNERAL DIRECTOR
R. C. Kirby
ADDRESS
Boston, 100
Reoelved and filed
OCT 2.9 1943
19
(Registrar of City or Town where deceased resided)
50m (e)-1-41-4667
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 made forthwith and transmitted on Form R-802 to the clerk Copies of returna of deaths recorded during the previous month which occurred in your city or town in case the deceased
WIIIL PLAINLY.
1
PLACE OF DEATH
(Usual place of abode)
(If U. S.
War Veteran,
( soity WAR)
1943
That I attended deceased from
(Give maiden name of wife in full)
Months
Days
1
M R-305
PLACE OF DEATH
SUFFOLK (County) BOSTON
(City or Town)
Mass. General Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return)
869350
Registered No.
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Matthew J. Lambert
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residenoe. No.
(Usual place of abode)
82 Waldemar Avenue
St.
(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
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
September
23
(Month)
(Day)
(Year)
2119 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.) Spontaneous cerebellar hemorrhage Glioma left cerebellartobe love Hypertensive Heart disease; said to have been in motor collision at Boston Les. 23. 1943
20 Acoldent, suloide, or homloide (specify) Date of occurrence 19
Where did Injury occur ? (City or town and State)
Did injury oocur in or about the home, on farm, in industrial place, or in pubiio place? (Specify type of place)
Manner ofSaid to have been in a m. tor
Injury
Nature of
collision at Boston on Sept 22 1943
Injury
While at work ?
.Was there an autopsy ?.
yes
21 Was disease or Injury In any way related to occupation of deceased?
If so, speolfy
"J. Brickley
M. D.
(Signed)
(Address)
Boston, Mass.
Date.
9-23
19
43
22
winthrop Cem.
iinthrow,
ass .
Piace of Burial, Cremation or Removal.
(City or Town)
Cent. 27
43
DATE OF BURIAL
19
23 NAME OF
FUNERAL DIRECTOR
J. F. O'Yaley
ADDRESS
Winthrop, ass.
Received and filed
001 1 1913
19
(Registrar of City or Town where deceased resided)
25m (h)-1-41-4667
No. 3 SEX M (or) WIFE of AGE Usual 9 Occupation : 10 or Business : PARENTS occurred. (See Chap. 46, Sec. 12, G. L.) of the city or town in which the deceased resided as soon as possible after the close of the month in which the death resided in another city or town at the time of death should be made forthwith and transmitted on Form R-305 to the clerk Coples of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased Industry Shoe
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCER
(write the word)
7. damm
5a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(Husband's name in full)
53
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that faot here.
8 58 Years Months.
2 Days
If less than 1 day .Hours Minutes
Shoe Broker
11 Soolal Security No.
030-09-1774
12 BIRTHPLACE (City)
(State or country)
East Boston, Mass.
13 NAME OF
FATHER
Louist Lambert
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston, ass.
15 MAIDEN NAME
OF MOTHER
Mary l'agee
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston, Lass.
17 Informant (Address)
Relation, if any
A TRUE COPY.
ATTEST :
Francis
( Registrar of city or town where death occurred)
DATE FILED
Cert. 27
43
Deep. 34, Book.I
St.
(If U. S.
War Veteran,
specify WAR)
Winthrop
1943
Married
Leonora Harmond-
1
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 Wwwwwwww ww yout chy of tewe in case the deceased resided in another city or town at the time
50m-10-'39. No. 8427-f
17
Informant.
Oscar Bucknam
Relation, if any son
(Address) 180 Somerset Ave, Winthrop
A TRUE COPY.
ATTEST:
(Registrar of city or down wortdeath occurred)
DATE FILED
Sent. 28, 1943
19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
September
24
1943
(Month)
(Day)
(Year)
IS | HEREBY CERTIEY.
That I attended deceased from
Sept. 24
19.70
..... , to.
19
43
(oz) WIFE of
Alonzo Bucknam
(Husband's name in full)
.years
6 Age of husband or wife if alive. 7 IF STILLBORN, enter that fact here.
8
AGE .. 9.0
Years
7
Months.
2.3Days
lf less than 1 day Hours ......... Minutes
Usual
9 Occupation:
Housewife
Industry
10 or Business:
Own home
11 Social Security No ..
none
Bath
12 BIRTHPLACE (City)
(State or country)
Maine
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings : Of operations
Underline the cause to which death
Of autopsy
What test confirmed diagnosis ?
should be charged sta- tistically.
20 Was disease or Injury In any way related to occupation of deccased ? no
If so, specify.
(Signod)
Harry ............ Campbell.
, M. D.
(Address) ...... 538 High St.
Dat
9/21
19
43
21 PLACE OF BURIAL, CREMATION OR REMOVAL Woodlawn. Cem. Everett (Cemetery) (City or Town)
DATE OF BURIAL
Sept. 27, 1343
19
22 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS
Winthrop, Mass.
Received and filed
OCT 15 1343
19
(Registrar of City or Town where deceased resided)
Y
R-302
PLACE OF DEATH
Middlesex.
(County)
Medford
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Medfor d (City or town making return) 200
Registered No ...
(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
2 FULL NAME
Adriana ... Bucknam
(If deceased is a married, widowed or divorced woman, give also maiden name.)
993 Shirley .st.
.........
.St.
Winthrop
(If nonresident, give city or town and state)
(Specify whether)
years
3
months
days.
In this communityLO yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE 5 SINGLE
MARRIED
white
WIDOWED
or DIVORCED
(write the word)
widow
5a lf married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
I last saw h
Oralive on
Sept. 2 4
., 19 4.3
death is said
to have occurred on the date stated above, at
3. 50Р
.m.
Duration
Immediate cause of death
Chr. Vascular Myocarditis
?yrs
Duc to
Due to
13 NAME OF
FATHER
Unable to obtain
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF MOTHER (City) (State or country)
Date of.
July
1
(1: U. S.
War Veteran,
specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay : In hospital or institution.
11050
No.
34 Grove St .mery Rest Home
-301 A
Justalp
(County) Winthrop (City or Town) 366 Pleasant St
The Commontoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent. 201
Registered No.
§ ( If death occurred in a hospital or institution, give ite NAME instead of atreet and nuniber)
homas Thomas F. Hawes
( If deceased is a married, widowed or divorced woman, give also/ maiden name.)
366 Pleasant
St.
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution
(Before death)
(Specify whether)
yeara
months days.
in this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male Mute
4 COLOR OR RACEJ
5 SINGLE
( write the word)
MARRIED
DI ORSEndowed
5a If married, widowed,
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