USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1950 > Part 43
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NO
222. ACCIDENT, SUICIDE, HOMICIDE (Specify)
22b. PLACE OF INJUNY (e.g., in or about bome, farm, factory, street, omce bidg., etc.)
22c. WHENE OID
INJUNY OCCUN?
(City or town)
(County)
(State)
224. TIME (Month) OF INJUNY
(Day) (Year)
(Hour)
22e. INJUNY OCCUNNEO While at
Not While
Work
at Work
Ing 1999, to Mart. 2, 1950, that I last saw the
2. I hereby certify that I attended the deceased from deceased alive on Mar 2, 1950, and that death occurred at/02 R.m., from the causes and on the date stated above.
24a. SIGNATURE
241. ADDRESS M. D. 22 Ileno Fallo Ky. man 2 19.50
251. PLACE OF BUDIAL CREMATION ON REMOVAL
25h. DATE
261. UNDENTAKEN'S SIGNATUNE Brant Jake Cemetery May 6 1950 Bel amithage 4117 LICENSE NO. 27. OATE FILEO BY LOCAL | 28. NEGISTRAN'S SIGNATUNE
200 UNDERTAKEN'S AOONESS
Della Pona
ed)
1950
Burial or Permit issued by France Transit
Date of issue 3/4
50 19
stitution, number)
tate)
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
(See Reverse for Instructions)
Form VS No. 60b. 5-25-49-10M Books (9D-101)
BE LEGIBLE, THIS IS A PERMANENT RECORD. PENCILS, COLORED INKS, OR BALLPOINT PENS SHOULD NEVER BE USED. SIGNATURES SHOULD TYPEWRITE, HAND-PRINT, OR WRITE LEGIBLY IN PERMANENT BLACK OR BLUE-BLACK INK. THIS CERTIFICATE MUST BE FILED WITH THE LOCAL REGISTRAR WITHIN 72 HOURS AFTER DEATH MARGIN RESERVED FOR BINDING
Dist. No:$ 6.59 To be inserted by registrar
Registered No ...
2. USUAL RESIDENCE (Where deceased Ured. If kutttution: residence before b. COUNTY a STATE/ March admission).
€. TOWN
e. STREET ADDRESS 600 Shirley At.
S
te the word)
1. IF MARRIED, WIDOWED DN OIVORCEO, Name of
Penale white
14. FATHER'S NAME, James me laveille AGWAS DECEASED EVEN IN .U. S. ANMEO FONCES! SOCIAL SECURITY NO. 18. INFORMANT'S ONN SIGNATURE (LE-ray, gire war or dates of service 604-09-1708 William H. Daisy Wiehey There
CAUSE OF DEATH
INTENVAN DETWEEN ONSET AND DEATH
ing life)
MEDICAL CERTIFICATION
22f. HOW DID INJUNY OCCUN?
Me. DATE SIGNED
(City or town making return)
RM R-302 1
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, 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
25m-(b)-11-49-900,475
PLACE OF DEATH
Suffolk (County)
Revere (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
Revere
(City or town making return)
131
Į(If death occurred in a hospital or institution, St. \ give its NAME instead of street and number)
2 FULL NAME.
Mary E. Goodwin (Finnerty)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
15 Wheelock
........
St.
Winthrop
(Usual place of abode)
(If nonresident, give city or town and State)
30
Length of stay: In place of death
.years.
6
months
.days. In place of residence.
years
.months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
8
1950
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
March ... 1
19
50
to.
July
8
19
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
William F. Goodwin
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Uremia
1 day
8.0
12
AGE
Years.
Months
.. Days
If under 24 hours
Hours.
Minutes
13 Usual
Housewife
10 day occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Mass.
Major findings:
Of operations
no
Date of operation.
no
What test confirmed diagnosis?
clinical ..... signs
5 Was disease or injury in any way related to occupation of deceased? no
If so, specify
(Signed) James ....... Burns
M.
(Address)
Everett
Date
7/9/
19 50
6 Winthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
July
11
19
501
Harry Goodman
7 NAME OF
FUNERAL DIRECTOR
John F. O'Naley
ADDRESS
Winthrop
Received and filed, AUG 24 1950 AtG & # 1850 .19.
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
Was autopsy performed?
no
FATHER (City).
Randolph
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Catherine Gorman
20 BIRTHPLACE OF
MOTHER (City)
Bo.s.ton
(State or country)
Mass
Informant.
(Address)
150Wheelock St.
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
July
12
19 50
MARRIED
WIDOWED
or DIVORCED
Widowed
I last saw h
... Or .. alive on
July
8 19 50 ath is said to
have occurred on the date stated above, at
9:30
INTERVAL BE-
TWEEN ONSET
ANO DEATH
11 IF STILLBORN, enter that fact here.
ANTE
CEDENT
CAUSES
(b)
Due To Diverticulitis
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
50
9 COLOR OR RACE
10 SINGLE
(write the word)
8 SEX
Femal
White
-
(Was deceased a
U. S. War Veteran,
if so specify WAR)
Registered No.
No.
Grover Manor Hospital
.
Winthrop
17 NAME OF
FATHER
Edward Finnerty
Boston
...
RM R-302 1
PLACE OF DEATH
Suffolk
(County) Chelsea
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Chelsea
(City or town making return)
Registered No. 46432
f(If death occurred in a hospital or institution. St. [ give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
29 Myrtle Ave.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death ...... ... years ............ months. .days. In place of residence ... years
11
.. months.
...... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July 31 1950
(Month)
(Day)
(Year)
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Married
4 I HEREBY CERTIFY,
Jan.
19
40
That I attended deceased from
to
July 31
19
50
I last saw h
im
alive on
July 31
19
5&ath is said to
have occurred on the date stated above. at
m.
INTERVAL BE- TWEEN ONSET AND DEATH 2 das
11 IF STILLBORN. enter that fact here.
·12
AGE.54 Years ..
.1
.Months
1
Days
If under 24 hours
Hours .....
.. Minutes
13 Usual
Occupation :.
Electrician
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Russia
17 NAME OF
FATHER
Jacob Bernstein
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Annie (cannot be learned)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21
Informant. Anne ..... Bernstein
(Address)
29 Myrtle Ave Winthrop
7 NAME OF
FUNERAL DIRECTOR
Benjamin Birnbach
ADDRESS
10 Washington St Dor
Received and filed
AUG 1 1 1950
19
(Registrar of City or Town where deceased resided)
?
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Thrombophlebitis
left leg.
?
Major findings:
Of operations.
Date of operation
. Was autopsy performed?
no
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, speciMenry Motliver
(Signed).
M. D.
284 Wash. Ave. Choale. 7/31.
.19 ..... 50
(Address)
Winthrop Cem Everett Mass 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Aug . 1, 1950
19
PARENTS
25m-(b)-11-49-900,475
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
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
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.)
No.
Chelsea Memorial Hospital
·
Morris Bernstein
(Was deceased a
WWI
U. S. War Veteran.
{ if so specify WAR)
Winthrop, Mass.
(a) Residence. No. (Usual place of abode)
10a If married, widowed, or divorced
HUSBAND of
Anne .Kaplan
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH
cerebral hemorrhage
ANTE
CEDENT (b)
CAUSES
Due To
Bronchial asthma
A TRUE COPY
Joseph G. Tyrrell
ATTEST:
(Registrar of City or Town where death occurred) July 31,1950
DATE FILED
19
RECEIVER
1
AUG1 _1950 AM
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
Suťfolk
(County) Boston
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
6612
....
Mass. Memorial Hospital
.
[(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
267 Washington Ave.
St.
Winthrop Mass.
(a) Residence ..
No.
(Usual place of abode)
57
.days. In place of residence.
.years.
months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August 1/50
8 SEX
F
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
Jan. 14
19
to
August 1.
19
50
I last saw h ...
.er ... alive on
August 1 1, 50
death is said to
(or) WIFE of.
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Cardiac arrest
11 IF STILLBORN, enter that fact here.
12
AGE
65
Years
.Months.
.Days
If under 24 hours
.Hours ...
.Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No ...
None
16 BIRTHPLACE (City) ... England (State or country)
17 NAME OF
FATHER
Thomas Jennings
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
Date of operation
Aug/1/50Was autopsy performed?
No
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? No
If so, specify.
WA Whitcomb
(Signed)
(Address)
Mass Memorial Hosat
8-1 50
19
6
Place of Burial or Cremation (City of Town)
DATE OF BURIAL.
August 4/50
19
21
Informant
(Address)
W C Finlayson
7 NAME OF
FUNERAL DIRECTOR
H S Reynolds
ADDRESS
Winthrop Mass
Received and filed.
AUG 14 1950
19
(Registrar of City or Town where deceased resided)
PARENTS
19 MAIDEN NAME
OF MOTHER
Elisabeth ---
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
August 7/50
.19 ..
X
TWEEN ONSET AND DEATH
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Ca of rectum
25m-(b)-11-49-900,475'
No.
Jane Finlayson
(Was deceased a
U. S. War Veteran,
( if so specify WAR)
(If nonresident, give city or town and State)
Length of stay: In place of death
......
.years.
months.
18
50
10a If married, widowed, or divorced
HUSBAND of
William D Finlay's &W
have occurred on the date stated above, at
12;15P
.. m.
INTERVAL BE-
Ca of rectum
Winthrop Cem-Winthrop Mass.
RM R-301A 1
PLACE OF DEATH
Suffolk Winthrop County)
Boston 9/8/60
The Commonwealth of Massachusetts EDWARD J. CRONIN, SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
131
(City or Towny Winthrop Community Host. No. .
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
Rosina Ferrara 2 FULL NAME ..
(If deceased is a married, udowed or divorced woman, give also maiden name.) 170 Lexington It
St.
East
PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran. if so specify WAR) Besten
none
(a) Residence. No. (Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death. ... years
months .. .. 7. days. In place of residence
50
.years
.months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Monthet
2 1950 (Day) (Year)
8 SEX Female
9 COLOR OR RACE
Muito
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word) Widowed
4 I HEREBY CERTIFY,
7/24
19
50
to
Queg 2
1950
death is said to
have occurred on the date stated above, at INTERVAL BE- TWEEN ONSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) .
bullar type
Cerchal Hemorrhage
7 day
13 Usual
Occupation:
at Home
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No. none
16 BIRTHPLACE (City)
(State or country)
italy
17 NAME OF FATHER
Michael Laudicina
18 BIRTHPLACE OF FATHER (City) (State or country)
Italy
19 MAIDEN NAM OF MOTHER Theresa Ponza
20 BIRTHPLACE OF MOTHER (City) (State or country) .
Italy
Benjamins Auxrais
DATE OF BURIAL
aux 5
1900
7 NAME OF
FUNERAL DIRECTOR
Frederick & magrath
ADDRESS East Boston
Received and filed.
AUG 3 1950
19
(Registrar)
PARENTS
5 Was disease or injury in any way related to occupation of deceased? wo
If so, specify
(Signed)
D. D. Potito
M. D.
(Address) 17a Beusing In St Date 8/2 19.50
6 Italy Cerosa Place of Burial or Cremation
mulden -
(City or Town)
50M-2-19-25666
STRUCTIONS FOR AL CERTIFICATE In giving E OF DEATH
not enter re than one se for each ), (b) and (c)
is does not mean de of dying, such failure, asthenia, means the disease, plications which death.
orbid conditions. giving rise to the ause (a) stating derlying cause
nditions contrib- the death but not to the disease or n causing death.
OTHER SIGNIFICANT CONDITIONS
Major findings:
Of operations.
Date of operation. Was autopsy performed ?.
What test confirmed diagnosis?
10-15 Jean.
Due To asterio schematic head
(c)
2 year
10a If married, widowed, or divorced "(Give maiden name of wife in full) HUSBAND of antonio Ferrara (or) WIFE of (Husband's name in full)
11 IF STILLBORN. enter that fact here.
12
78
Years
Months
.. Days
If under 24 hours
.Hours . Minutes
ANTE CEDENT (b) CAUSES
Due To arteriosclerosis
That I attended deceased from 50.
I last saw her
alive on
aug 2
5:30P
m.
Registered No.
21
Informan
(Address)
1170 Lesmyten At E Bita
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Walter & Tallos (Signature of Agent of Board of Health or other) Health Office 8/4/50
(Official Designation) (Date of Issue of Permit)
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 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.
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen, G. L. Chap. 46, Sec. 10.
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 shallexhume a human body and remove it front 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 delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, 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 purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, 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 desiring 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 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 registra- tion. The person to whom the permit is so given and the physician 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 .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
Medical examiners shall make cxaminatinn upon the view of the dead bodies of persons as are supposed to have died by violence, nr by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable discase, or when any person is found dead. .. - General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
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 occup :- 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
M 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.
135
No. 69 John202 Que.
J(If death occurred in a hospital or institution, St. \ give its NAME instead of street and number)
Lende 22 De Boardman 2 FULL NAME ..
PHYSICIAN - IMPORTANT (Was deceased a
U. S. War Veteran, if so specify WAR)
67 Johnson ave. St.
(a) Residence. No. (Usual place of abode)
(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
MaLE
9 COLOR OR RACE White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word) in dezeed
10a If married, widowed, or, divorced HUSBAND of. libia De Coleman
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
83
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:
retired
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
way MiAL
17 NAME OF
FATHER
WILLIAM FALAM110
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Vermont
19 MAIDEN NAME
OF MOTHER
Ellen Blaisde LL
20 BIRTHPLACE OF MOTHER (City) (State or country) Vermont
21 Informant (Address)
mess Co 2 × man
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Walter Af Khaberg.
(Signature of Agent of Board of Health or other},
Tilalle Lucer
(Official Designation) (Date of Issue of Permit)
100M-(D)-10-46-24658
7 NAME OF
FUNERAL DIRECTOR
Mauricew Ierby
ADDRESS winthrop
Received and filed.
AUG 8 1950
19
(Registrar)
yum
ANTE CEDENT (b) CAUSES Provotétée
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? 2
If so, specify
(Signed)
(Address)
6
Winthree
winthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
10/ 2
M. D.
Date FAS- 1958
PARENTS
4
19.56 (Year)
(Month)
4 HEREBY CERTIFY,
19.5.0 to
last saw h
4 .alive on
19 Meath is said to
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