USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1949 > Part 28
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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.
No undertaker or other persons shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the 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 observance of the follow- ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deathsonly 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 occupation, 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 import- ant, 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 occupz- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
+
DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
State File No. Registrar's No. 89
1. PLACE OF DEATH:
(a) County
Carroll
(a) State Mass.
(b) County
Suffolk
(6) City or town
No ... Conway
(c) City or town
Winthrop
(If outside city or town limita, write RURAL)
(c) Name of hospital or institution:
Memorial Hospital
(d) Street No.
4] Buckthorn Terrace
(If not in hospital or institution, write street ffumber or location)
(If rural, give location)
(d) Length of stay: In hospital or institution
In this community
3.days
(Specify whether
years, months or days)
3. (a) FULL NAME
Ernestine Belle Scribner
20. Date of death: Month
day
3. (b) If veteran,
name war
3. (c) Social Security
No. . None
year
hour 8 PM
minute
21 I hereby certify that I attended the deceased from
5. Color or
4. Sex Female
race
White
6. (a)Single, widowed, married)
divorced
Widowed that Nast saw h
Ma
1
19.49, to
May
4
19.49:
alive on
May
4
19.49
6. (b) Name of husband or wife
6. (c) Age of husband or wife if ( and that death occurred on the date and hour stated above.
years
alive
Immediate cause of death Cerebral hemorrhage
7. Birth date of deceased Mayr
12
1874
(Day)
(Year)
8. AGE:
Years
Months
Days
If less than one day
hr.
min
9. Birthplace
West Falmouth,
Maine
10. Usual occupation
Housewife
11. Industry or business
Other conditions. Landude pregnancy within 3 months of death)
PHYSICIAN
[12. Name
Neal.Prince
13. Birthplace
(City. town, or county)
Major findings:
(State or foreign country)
Code:
331X
14. Maiden name
Jennie Knight
Of operations
15. Birthplace
(City, town, or county)
(State or foreign country)
16. (a) Informant's own signature ....
Arthur Q. Jackson
(b) Address.
22. If death was due to external causes, fill in the following:
(a) Accident, suicide, or homicide (specify)
(b) Date of occurrence
(c) Where did injury occur?
(City or town) (County) (State)
(d) Did injury occur in or about home, on farm, in industrial place, in public place?
(Specify type of place)
While at work?
(e) Means of injury
23. Signature G.H. Shedd
(M. D. or other) M.D.
Address No .... Conway, New Hampshire Date signed/6/49
8-6917 JUL 2 1 1949
S. GOVERNMENT PRINTING OFFICE 16-13493
=
(BCgIorias Us Wit) VI .....
Underline the cause to which death should be charged sta- tistically.
17. (a)
Burial
(b) Date thereof 5 /10/1949
(Month) (Day) (Year)
(c) Place; burial or cremation
(Burial, cremation, or removal)
Woodlawn Cemetery
Everett,
Mass.
18. (a) Signature of funeral director
ArthurH. Furber
(b) Address
No ... Conway,New Hampshire
19. (a) 5/7/1949
(6)
Eral F. Burnell
(Date received local registrar)
(Registrar's signature)
Due tp Arteriosclerosis
Unknown
74
Due to
City. town. or count
(State or foreign country)
MOTHER FATHER
Of autopsy
Duration 3 days
(Month)
) If foreign born, how long in U. S. A .?
years.
MEDICAL CERTIFICATION
2. USUAL RESIDENCE OF DECEASED:
State of
NEW HAMPSHIRE
(If outside city or town limita, write RURAL)
RM R-302
Suffolk
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Chel sea
(City or town making return)
1
PLACE OF DEATH
(County)
Chelsea
(City or Town)
No. U. S. Naval Hospital
St.
(If death occurred in a hospital or institution, give its NAME instead of atreet and number)
2 FULL NAME
O'NEILL, John Peter
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
887 Shirley St. Winthrop, Mass
(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
23 days.
In this community
20 yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX male
4 COLOR OR RACE
white
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
widowed
5a If married, widowed, or „divoroed
HUSBAND of
Margaret .... Murphy
( Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that fact here.
8
AGE .... 7.3 .... Years.
Months.
Dayı
If less than 1 day
Hours ......
Minutos
Usual
9 Occupation :
U .S .Navy Retired
Industry 10 or Business :
11 Soolal Security No ...
12 BIRTHPLACE (City)
(State or country)
Ireland
13 NAME OF
FATHER
Peter O'Neill
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
15 MAIDEN NAME
OF MOTHER
Cannot be learned
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Margaret Grimes Relationihre by
Informant
(Address)
887 Shirley St. , winthrop, Mass
A TRUE COPY.
ATTEST :
(Registrar of city or town where death occurred)
DATE FILED .19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
June 6, 1949
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY,
May 14
19
49
to
June
6
That I attended deceased from
I last saw h ... i.m ...
... alive on.
June 6
19 .... 49death is sald to
have occurred on the date stated above, at 7:35 p.
.. m.
Duration
Immedlate cause of death
Generalized
Carcinomatosis
1 mo
Due to
Due to.
Other conditions
(Include pregnancy within 3 months of death)
Major
Gastric C. A &Carcinoma
Of operations
tosis
Date of
4/9/49
Of autopsy
Yes
What test confirmed diagnosis ?... Bi.o.p.s.y.
20 Was disease or Injury In any way related to oooupation of deosased ?.
If so, speolfy
(Signed) William h. Fundles
Date
6/7/2049
M. D.
(Address)
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Calvary
Boston
DATE OF BURIAL
June
1949
(City or Town)
19
22 NAME OF
FUNERAL
PIRECTOR
John F.
O'Maley
ADDRESS
Alantic St., winthrop, Mass
Received and filed
JUL -2-0 1949
19
(Registrar of City or Town where deceased resided)
.
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the olerk 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.)
50m· (b) ·6-44-14607
Spanish
(If U. S.
World I
War Veteran,
speolfy WAR)
World 2
90
Registered No.
354
Physician Underline the cause which death should be charged sta- tistically.
RM R-302 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 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 WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
PLACE OF DEATH
Suffolk (County)
Revere
(City or Town) 214 Endicott Ave. No.
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Revere (City or town making return)
Registered No.
91
j(If death occurred in a hospital or institution. St. \ give its NAME instead of street and number)
2 FULL NAME Everett Barlow Cartwright
.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 614 Shirley
St.
Winthrop
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death
.......... years.
days. In place of resident
years.
.months
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June
7.
1949
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
May .... 27
1949
to ..
June ........ 7.
19449
I last saw h.1m alive on ..
J.un ........
7
..... +9
death is said to
10a If married, widowed, or diwertha Floyd
HUSBAND of
(Give maiden name of wife in full)
have occurred on the date stated above. att: 30
A
.. m.
INTERVAL BE-
TWEEN ONSET
ANO DEATH
11 IF STILLBORN, enter that fact here.
AGE 3
.. Years
Months.6
Days
If under 24 hours
Hours ....
. Minutes
13 Usual
Occupation :
Piano Tunner
ANTE
CEDENT (b)
CAUSES
Due To
Arteriosclerotic
heart disease
12 mos
14 Industry
Self employed
or Business:
15 Social Security No ..
027-14-3927
OTHER
SIGNIFICANT
CONDITIONS
Diabetesmellitus
? yrs
17 NAME OF
FATHER
Edmund Cartwright
Major findings: Of operations.
Date of operation
Was autopsy performed?No
What test confirmed diagnosis Clinical
19 MAIDEN NAME
OF MOTHER
Kate McCloy
5 Was disease or injury in any way related to occupation of deceased ?. J.O. If so, specify. (Signed Paul P. Weinsaft
23 Sademore Drive Winchmay 6/7/ 149
6
Linwood .... Cemetery ........
Place of Burial or Cremation
(City or Town)
Haverhill ..... Mass.
DATE OF BURIAL
June 9
19.41.9
7 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS winthrop, Mass.
Received and filed
JUL 14 1949
19
(Registrar of City or Town where deceased resided)
PARENTS
20 BIRTHPLACE OF
Salem
MOTHER (City)
(State or country)
Mass.
21 Edmund S. Cartwright
Informant
(Address )5 Johnson Ave, Winthrop
A TRUE COPY.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED June 10
19
49
8 SEX
iale
9 COLOR OR RACE
White
10 SINGLE
(write the word)
MARRIED Divorced
WIDOWED
or DIVORCED
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) ..... Coronary ..... thrombo.s1.s
30 min
(Kind of work done during most of working life)
Due To
(c)
Generalized
arteriosclerosis
? yra
Haverhill
16 BIRTHPLACE (City).
(State or country)
Mass
18 BIRTHPLACE OF
FATHER (City).
Boston
(State or country)
Mass.
50m-(e)-10-48-24658
20
(Was deceased a
U. S. War Veteran,
if so specify WAR)
RM R-302 1
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 WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
PLACE OF DEATH
Suffolk (County)
Rovere (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
COPY OF CERTIFICATE OF DEATH
Revere (City or town making return)
Registered No.
92.
No. 405.Washington Avenue
J(If death occurred in a hospital or institution.
St. [ give its NAME instead of street and number)
2 FULL NAME. Sara ... Schryver (If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
.3.39Cliff .... Avenue
(Usual place of abode)
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death.
........
.years ....
.. months ..
........ days. In place of residence .......... years.
.. months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
(write the word)
'emale
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Single
4 I HEREBY CERTIFY,
That I attended deceased from
...... Hov ...
19 44
to ...
June ....... 22 .........
149
I last saw her-
...... alive on ... June ······· 22 ........ 1949., death is said to
have occurred on the date stated above, 1 7 :30 pm.
INTERVAL BE-
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a).
Cerebro vascular
accident with left hemipl
TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE.86 Years.5.
.Months.
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :.
At .... home
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No.
16 BIRTHPLACE (City).
Portland
(State or country)
Maine
17 NAME OF
FATHER
S. Schryver
18 BIRTHPLACE OF
FATHER (City)
Amsterdam
(State or country)
Holland
19 MAIDEN NAME
OF MOTHER
Rosette Van Wechsel
20 BIRTHPLACE OF
MOTHER (City)
Amsterdam
(State or country)
Holland
21
Informant.
Rosalie M. Cobb
.N. Y.
(Address) ZQ Marmont Ave New York
7 NAME OF
FUNERAL DIRECTOR.
Frank S. Whitney
ADDRESS
Received and filed 30 Laurel Street-Melrose 19
JUL 1 4 1949
(Registrar of City or Town where deceased resided)
? yrs
OTHER
Fracture left hip,
CONDITIONS aled with nailing
6 yrs
Date of operation.
.Was autopsy performed ?.
No.
PARENTS
5 Was disease or injury in any way related to occupation of deceased ?.....
If so, specify ...
(Signed).pr
M. D.
Religine tapp 6/23/10/19
6
Place of Buflat of Cremation
Frerett
DATE OF BURIAL June 24 1919
A TRUE COPY.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
June 23
.19 49
3 DATE OF
DEATH
(Day)
ANTE
Due To
CEDENT (b)
Generalized
Due To
(c)
SIGNIFICANT
Major findings:
Of operations.
None
What test confirmed diagnosis? Clinical
2 TAdores hore Drive.
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
CAUSES
arteriosclerosis
50m-(e)-10-48-24658
.22.
1.949
(Year).
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
RM R-302 1
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 WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
3 DATE OF DEATH ANTE CEDENT (b) CAUSES Major findings: Of operations 6 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 CONDITIONS
50m-(e)-10-48-24658
PLACE OF DEATH
Suffolk (County)
Boston (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
Boston (City or town making return)
Registered No.
572 93
¡(If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
2 FULL NAME.
Harry Hammond
(If deceased is a married, widowcd or divorced woman, give also maiden name.)
(a) Residence. No.
20 Pleasant St
St.
Winthrop Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death
years
months.
4 .days. In place of residence
5
... years
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
4 I HEREBY CERTIFY,
June 24, 19 49
to
June 27/49
That
I
attended deceased
from
I last saw Him ... ... alive on .....
June ... 27
149
death is said to
INTERVAL BE-
TWEEN ONSET
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a). Myocardial infarction old
AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE
75 Years.
2
Months
20
.Days
If under 24 hours
.. Hours ... ... Minutes
13 Usual
Occupation :.
Building Estimator
(Kind of work done during most of working life)
14 Industry
Contracting Co.
or Business:
15 Social Security
010-07-3206
16 BIRTHPLACE Saratoga Springs New York (State or country)
17 NAME OF William Hammond
18 BIRTHPLACE OF
FATHER (Saratoga Springs New York
(State or country)
19 MAIDEN NAME
OF MOTHERArabella Ward
20 BIRTHPLACE OF
Saratoga Springs New York
MOTHER (City).
(State or country)
21
Informant
(Address)
Douglas Hammond
A TRUE COPY
ATTE Michael & Morning
(Registrar of City or Town where death occurred)
DATE FILED
Jun 29/49
.19
(Registrar of City or Town where deceased resided)
PARENTS
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
N A Wilhelm
(Signed)
Peter Bent Brigham Hospt 6-27-P9
(Address)
Greenwood Cem-Saratoga Springs
(City or ToNEW York
DATE OF BURIAL
Place of Burial or Cremation
June 29/49
19
7 NAME OF
FUNERAL DIRECTOR
H S Reynolds
ADDRESS
Winthrop Mass.
Received and filed 19
see above
Date of operation.
Was autopsy performed?
autopsy
10a If married, widowed,tor divorced C Holmes
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Due To Pneumonia, right lobe, lower
Due To Bronchiectasis , peptic ulcer (c) diverticulitis, sigmoid colon
OTHER
SIGNIFICANT
Arteriolar nephrosclerosis
Medical Examiner Declined JurisdictionATHER
What test confirmed diagnosis?
June 27/49
(Month)
(Day)
(Year)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(Usual place of abode)
Peter Bent Brigham Hospital
No.
1
have occurred on the date stated above, at
2;05A
m.
COPY OF THE RECORD OF A DEATH
Returned to the clerk of .... Winthrop,
Mass.
as is provided in Section 383 of Chapter 22, 1944 R. S.
Full name.
Vera Small Silva
Place of death Old TownPenobscot ,Maine (If outside city or town liniits, write RURAL) Home Private' Hospital
Name of hospital or institution
(If not in hospital or institution write street No. or location)
Length of stay: In hospital or institution In this community.
Usual residence of deceased: State ..... Mas.s.
County.
City or Town.
Winthrop
Street No.
If veteran, name war
Social Security No.
005-22-4208
SexFemale Color.
White
.Married, Single,
Widowed or Divorced.
Married
Name of husband or wife.
Age of husband or wife, if gliys
Aug
14
Birth date of deceased: Year ...
Month.
Day ......
Age: Years ... 44 Months.
Days ...........
.If less than
one day
hr.
minutes
Birthplace ...
Old Town,
Maine
(City, town or county) (State or foreign country)
Usual occupation
Housewife
Industry or business.
Father: Name.
Harry Wilber Small
Occupation
Birthplace.
(City, town or county) (State or foreign country)
Mother: Maiden name Maude Duplissa
Birthplace.
(City, town or county) (State or foreign country)
Name of informant Mrs . Maud Campbell
Date of death: MonthJune Day29
Year 1949
Immediate cause of death Essential Hypertension Duration
Due to.Cerebral Hemorrhage
Other conditions (Over)
JUL 13 1949
Of autopsy. No
If death was due to external causes, fill in the follow- ing:
Accident, suicide, or homicide (specify) ..
Date of occurrence ..
Where did injury occur ?.
Did injury occur in or about home, on farm, in indus- trial place, in public place ?.
While at work ?.
Means of injury ..
Name of physicianLouis L.Theriault, M.D.
P. O. Address.
Old Town, Maine
Place of burial.
Old Town, Maine
Date of burial.
July 1, 1949
Name of Cemetery.
Forest Hill
Funeral Director (Embalmer Everett T.Nealey
P. O. Address.
Old Town, Maine
Date when received by Town Clerkune 30, 1949
State of Maine
I hereby certify that the above is a true copy of the
Record of a Death made by the clerk of .. old Town
in the month of
AJune
.. 19
40
Elisabeth Isable
Clerk of ...
old Town
...
Dep.
M R-302 1
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 after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
50m-(e)-10-48-24658
PLACE OF DEATH
(County)
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or town making return)
Registered No.
91.
J(If death occurred in a hospital or institution. St. [ give its NAME instead of street and number)
2 FULL NAME.
VERA SMALL SILVA
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. St. (Usual place of abode) Length of stay: In place of death .. years. months. .. days. In place of residence. .. years.
(If nonresident, give city or town and State)
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
19
to
19
I last saw h
.alive on
19
death is said to
have occurred on the date stated above, at
m.
INTERVAL BE-
TWEEN ONSET
AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE
.. 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)
19 MAIDEN NAME OF MOTHER
20 BIRTHPLACE OF MOTHER (City) (State or country)
21 Informant (Address)
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
.19
..... ....
(Registrar of City or Town where deceased resided)
10a
If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations
Date of operation.
.Was autopsy performed?
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? If so, specify (Signed) (Address) Date
M. D.
19
6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL. 19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed 19
PARENTS
3 DATE OF
DEATH
June
29
1949
That
I
attended deceased from
(Was deceased a
U. S. War Veteran,
if so specify WAR)
No.
A R-301A 1
PLACE OF DEATH
Suffolk (County) Winthrop (City or Town)
The Commonwealth 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.
Registered No. 95
Washington Are Kirkpatrick Nursing Home No.
[(If death occurred in a hospital or institution, St. ) give its NAME instead of street and number)
Frank & Corbett 2 FULL NAME ..
(If deceased is a married, widowedef divorced woman, give also maiden name.)
62 Crystal Gore Ave.
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death. years. 4 .. months. days. In place of residence years months . . days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
(Month)
(Day)
2 1949. (Year)
8 SEX Male
9 COLOR OR RACE
White
10 SINGLE MARRIED- WIDOWEDMarried or DIVORCED
4 I HEREBY CERTIFY .
Jan 5
1947
...
to
Only
2
1049
I last saw
has alive on.
, 1947, death is said to
10a If married, widowed
HUSBAND of
(Give maiden name of wife/in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 76
.Years
Months Days
If
If under 24 hours
Hours ... . Minutesª
13 Usual
Occupation :
Retired Letter Carrier (Kind of work done during most of working life)
14 Industry
or Business:
U.S. Post Office
15 Social Security No.
none
10
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