USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1952 > Part 63
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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 examination upon the view of the dead bodies of persons as are supposed to have died by violence, or 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 disease, 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 c é po py 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 ermetery of burial ground in which the interment is made.
1 Deyap: 114, Sec. 46, G. L., (Tercentenary Edition).
1.2
1
RULES OF PRACTICE
2
The fulfillment of the purpose of these laws calls for the observance of the follow- ng mes of practice!
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 any formfe bu jury.
Sersou
Board of Health physicians will certify to such deathsonly as those of wh though disabled by recognized disease unrelated to any form of edwithout recent medical attendance or whose physician is absent Lo Mex the certificate of death is needed.
Medical Examiners will investigate and certify to all deaths supposably due to'mjury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs ur poisons) thermal, or electrical agents, and deaths following abortion, but SEP-chs from disease resulting from injury or infection related to occupation. 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 occupa- 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.
PLACE OF DEATH
Auffach. (County)
(City or Town) No. 26 Thencola- Donato Paolino
(If deceased is a married, widowed or divorced woman, give also maiden name.)
26 Lincoln Il.
St.
(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 White
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCEPorAzila
(write the word)
10a If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
Flachica
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
70%
Months
Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation : .
Carpenter?
(Kind of work done during most of working life)
14 Industry
or Business:
petered.
15 Social Security No. .
16 BIRTHPLACE (City) (State or country)
17 NAME OF FATHER
Pasquale colino
PARENTS
18 BIRTHPLACE OF FATHER (City) (State or country)
Italy
19 MAIDEN NAME
OF MOTHER
Donata Scania same
20 BIRTHPLACE OF MOTHER (City) (State or country)
21 Informant (Address)
(Pasquale Savunma
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: W. E. Bakker
(Signature of Agent of Board of Health or other)
140
de RX 2/ 5%
(Official Designation)
(Date of Issue of Permit)
X
3 DATE OF
DEATH
30
1952
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
l'an.
195€
to Lag. 30
That I attended deceased from
62
19
(I last saw ham alive on
Ceux) 29, 1952 death is said to
have occurred on the date stated above, at m.
DISEASE OR CONDITIOX)
DIRECTLY LEADING
TO DEATH (a)
Cerebral Stemorrhage
INTERVAL BE- TWEEN ONSET AND DEATH
8/23/52
1950
Due To
Par kinsorian
(c)
Disease
1948
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation
What test confirmed diagnosis?
Was autopsy performed?
Clinicaltech.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ....
P. Centange
M. D.
(Signed)
(Address)
235. Huverialt
Date 8/30/5,20
6 Idoly Craft 515
melder
(City or Town)
Place of Burial or Cremation
DATE OF. BURIAL .... Sebf 2 - 52 19 19
7 NAME OF
FUNERAL DIRECTOR
ADDR
Received and filed.
SEP 3 1952
19
(Registrar)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No. 1.83
J(If death occurred in a hospital or institution. St. [ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran, if so specify WAR)
ONS FICATE 19517
g EATH ter one ach d (c)
ot mean ng. such asthenia. disease. s which
ditions. se to the stating cause
contrib- but not sease or g death.
+50M (B)-12-49.900722
301A 1
insalu SFULL NAME
(a) Residence. No. (Usual place of abode)
ANTE
Due To
Hypertension + Hypertension
CEDENT (b)
CAUSES
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 requesth Erdilexaminers shall inake examination upon the view of the dead bodies of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration ; standard certificate of death, stating to the of persons as are supposed to have died by violence, or 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 die.LEl'By recognizable disease, or when any person is found dead. - General Cher Sec. 6., as amended by Chap. 632. Sec. 4, Acts of 1945. 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 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 army, navy or marine corps of the United States in any war in which it has e engaged, insert in the certificate a recital to that effect. specifying the war. a 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 comhpl with any provision of this section, such physician or officer, shall forfeit ten dollar For the purposes of this section and of sections forty-five, forty-six and forty-severy 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 seventee 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 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 delivered to such board, agent or elerk, 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 pernuit. 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 of cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45. G. L., (Tercentenary Edition).
No undertaker or other persons shall bury a human body or the ashes thereof which havebeen brought into the commonwealth until he has received a permit atoda fron th thiard of health or its agent appointed to issue such permits, or board, from the clerk of the town where the body is to be buried or the funeral ister be held, or from a person appointed to have the care of the cemetery of fufal ground in which the interment is made.
fechp.1 .4, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
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 SEP An they had given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only 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 traumatismı (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 ean be known. Make some entry in this section for every person aged 10 years or over. If the occupa- 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 domestie service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, ete. For a person who had no occupation whatever write no.1e.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
3
+
PLACE OF DEATH
| SUFFOLK 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.
75287 84
[(If death occurred in a hospital or institution, No. Peter Bent Brigham Hospital XXSK( give its NAME instead of street and number)
2 FULL NAME
HARRY .... HURST
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
2.96 River
St.
Winthrop .....
.Mass ..
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.
... years.
.. months.
3
days.
In place of residence.
.years
months
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August
25.
1952
(Month)
(Day)
(Year)
PHEREBY CERTIFY,
Thatte
attended deceased from
8/22
19.
to.
8.25
19
52
We last saw h ..... i.m.alive on
8/25
19.52 death is said to
have occurred on the date stated above, at.
2 .: 25.p
.. m.
INTERVAL BE-
TWEEN ONSET
ANO .DEATH
DISEASE OR CONDITION DIRECTLY LEADING
TO DEATH (a)
Spontaneous ..... pneumo.
thorax c broncho-
Due To
pleural fistula
ANTE
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
heart disease
? yrs
Major findings:
Of operations.
Bronchoscopy
Date of operation
8/25/52
Was autopsy performed?
INN.O
What test confirmed diagnosis?
Clinical
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
M. D.
(Address)
Date ...
8/25
.19 .. 52
Wall .... St ... Com. Place of Burial or Cremation (City or Town)
Woburn
DATE OF BURIAL
August 26
19 .... 52
21
Informant
(Address)
A .... Sherman
7 NAME OF
FUNERAL DIRECTOR
H J Torf
ADDRESS
Chelseas
19
(Registrar of City or Town where deceased resided)
11 IF STILLBORN, enter that fact here.
12
AGE ... 65.Years.
Months.
Days
If under 24 hours
Hours
. Minutes
1cmon 13 Usual
Occupation :
Stitcher
(Kind of work done during most of working life)
14 Industry
or Business:
Clothing
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Russia
17 NAME OF
FATHER
Peter Hurst
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Tillie
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
A TRUE COPY
Charles 2 Mack
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
August 27
19
52
.
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
25m-(b)-11-49-900,475
6
(Signed)
P .... B.B.H.
Cass
PARENTS
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Married
10a
If married, widowed, or divorced
HUSBAND of
Rebecca Surm.n.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Arteriosclerotic
C
-302
1
Received and filed. SEP 22 %
(Was deceased a
U. S. War Veteran,
{ if so specify WAR)
No
RECEIVE!
TOV
OF
11 12 1
OFFICE
10
3
MIN
CLERK
5
6
155
SEP22
AM
-
..
302
1
Cambridge
(City or Town) No.Holy Ghost Hospital
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MU COPY OF CERTIFICATE OF DEATH
Cambridge
(City or town making return)
1268
Registered No.
1.85
S(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME
Michael O'Toole
(If deceased is a married, widowed or divorced woman, give also maiden name.) 50 Moore St.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death. ....... .years 1 months. 14 .days. In place of residence. .......... years.
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August
28,
1952
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
July ... 14 ...
19 .... 52.,
to.
August .... 28 .....
19 .. 52
I last saw h ... j.m .... alive on ......
.August ... 27.,, 19 .... 5.2death is said to
have occurred on the date stated above, at. .12.50 .4. . m.
INTERVAL BE-
10a If married, widowed, or divorced
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
78
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:
City of Boston
15 Social Security No.
none
16 BIRTHPLACE (City).
(State or country)
Ireland
17 NAME OF
FATHER
James O'Toole
18 BIRTHPLACE OF
Ireland
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Helen (Unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
6
New Calvary Con Boston Mass. Place of Burial or Cremation (City or Town)
DATE OF BURIAL ..
August 30, 1952
19
21
May Mi. Healy
Informant
(Address)
15 Jewett St. Roslindale
7 NAME OF
FUNERAL DIRECTOR
F.J.Higgins
ADDRESS
Roslindale Mass.
Received and filed.
SEP 22 1954
19
(Registrar of City or Town where deceased resided)
8 SEX
male
9 COLOR OR RACE
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
single
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Carcinoma of stomach
LO mos
ANTE
Due To CEDENT (b) CAUSES
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation
Was autopsy performed?
no
What test confirmed diagnosis ?.
biopsy
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
George C. Branche Jr.
(Address) .....
.... Holy Ghost .Hosp ........
8-28
Mr.D.
PARENTS
25M (E)-6-50-902253
X
Middlesex (County)
PLACE OF DEATH
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Ser 12, G. L.)
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
August 28- 1952
........ ............... 19
..........
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. (Usual place of abode)
Winthrop,Mass.
(write the word)
TWEEN ONSET AND DEATH
city of Boston
RECEIVED
OF
11. 12
CE
1
1:10
2
3
C
1
5
-
SEP22 AM
- --
ULEITKT
inite
L
PLACE OF DEATH
SUFFOLK GOUBOSTON
(City of 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.
8129 186
[(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME. Baby Bronstein (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. 3.8 .... Beach Rd ..
Winthrop, Mass. St.
(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
3 DATE OF
DEATH
September 1, 1952
(Day)
(Month)
(Year)
8 SEX
ma le
9 COLOR OR RACE
white
10 SINGLE
MARRIED
WIDOWED
single
4 I HEREBY CERTIFY.
That I
attended deceased from
Se.p.t .....
1952 ...... to .. Sept ..... ]
19.52
I last saw
imalive on.Sep.t ..... 1., ...... 1952
death is said to
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)
Prematurity
15 min
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)
Boston, Mass.
17 NAME OF
FATHER
Eugene Bronstein
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Cambridge, Mass.
1
19 MAIDEN NAME
OF MOTHER
Fay Scheenfein
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Winthrop, Mass
6
Place of Burtal or Cematin
Mt ... nnon-Workmen &Arele,
DATE OF BURIAL
Sept 3, 1952
19
21
Informant
(Address)
Father
A TRUE COPY
Winthrop, Mass.
7 NAME OF
FUNERAL DIRECTOR
Aaron Golov
Dorchester, Mass.
ADDRESS
Received and filed
Sept 18, 1958CT- 2 1952
(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 ..
A.M. Baker
M. D.
(Signed)
(Address)
... .
Beth Israel
.Date
9/1
19 ... 52
Major findings:
Of operations
Date of operation.
Was autopsy performed ?.
no
What test confirmed diagnosis ?.
11 IF STILLBORN, enter that fact here.
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
25m-(b)-11-49-900,475
of death should be transmitted on Form K-302 to the clerk of the city of town in which the deceased resided as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
302 1
No.
Beth Israel ... Hospital
(Usual place of abode)
have occurred on the date stated above, at.
1:47
8.
INTERVAL BE-
TWEEN ONSET
AND DEATH
(write the word)
ATTEST:
(Registrer of City or Town w
Charles A . "Heredeath cure)
19
RECEIVED
TO
OF
11.12
ERA
6
OCT-2'952 AM
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
No. Mayflower .... Rest ... Home
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
187
J(If death occurred in a hospital or institution,
39 Grovers Ave
S NAM
PHYSICIAN - IMPORTANT
(Was deceased a
No
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. 33 St. Andrew Rd.
St.
( East ) Boston
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.
.years
months.
14 .. days. In place of residence.
... years ..
months
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Self. 1
(Month)
(Day)
155-200
(Year)
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED Married
4 I HEREBY CERTIFY.
That I attended deceased from
19.3.
2
to.
Seff1
1052
I last saw him alive on
Sept 1
19>" ? death is said to
have occurred on the date stated above, at / 2 hour
INTERVAL BE-
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
TWEEN ONSET
ANO DEATH
5 ms
10a If married, widowed,
HUSBAND of
Rose Helen Cicco
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
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