USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1953 > Part 48
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"DentroW making return)
Registered No. 156
[(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
No. Danvers Stave Hospital, Hathorne
2 FULL NAME .. .....
(If deceased is & married, widowed of divorced woman, give also maiden name.)
(a) Residence.
No.
(Usual place of abode) Sea View Ave.
(If nonresttenthgiverity or town and State)
Length of stay: In place of death ......
.years ........... months ........... days. In place of residence.
years.
months.
... days.
4
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
J(Month)
(Day) 16, 1963
I HEREBY CERTIFY.
That I attended deceased from
June 12
...
1953. to July 16
19.53.
I last saw h
Lillalive on
July 15, 1953, death is said to
have occurred on the date stated above, at& .... O.O ............. m. INTERVAL BE-
TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE ....... Years. ].] .. ... Months24:
... Days
If under 24 hours
.Hours ......
Minutes
13 Usual
Occupation:
Retired
(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
James Timothy Jason
18 BIRTHPLACE OF
FATHER (City)
Portland
(State or country)
jaine
19 MAIDEN NAME
OF MOTHER
Annie A. . ulligan
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
I. B. Canada
21
Mary E. Sheehan
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred) U
DATE FILED
July
20
19
53
2
(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 ....
Andrew Nichols 3rd
M. D.
(Address)
(Signed)
Danvers, I ass. Date 7/17/
19.52.
6 Winthrop Cem. Winthrop
Place of Burial or Cremation (City or Town) 195.3
DATE OF BURIAL July 20
7 NAME OF
FUNERAL DIRECTOR John F. Oifaler
ADDRESS
Winthrop, "ass.
Received and filed. 19
=
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
10a If married, widowed, or divorced
HUSBAND of.
Gertrude F .DeAngel:
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
Arteriosclerotic
TO DEATH (a)
heart disease
ANTE
Due To
Generalized
CEDENT (b)
CAUSES
Arteriosclerosis
years
Due To (c)
OTHER
Bronchopneumonia
SIGNIFICANT
CONDITIONS
Major findings:
Of operations
Was autopsy performed ?.
What test confirmed diagnosis?
Date of operation
Clinical & Laboratory
3 days
25M.(B)-11-51-905807
M R-302 1
X
Informant.
(Address)
Hathorne, HASS.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
St.
TO:
THROP.
AUG10
IR-301A 1
PLACE OF DEATH
Count Y
City or To)
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.
157 1
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,
St.
(If nonresident, give city of town
. . months. .days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July
17
1953
(Year)
(Month)
(Day)
That I attended deceased from
to ..
lutz 12
1952
1953.
death is said to
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
prematantes
INTERVAL BE- TWEEN ONSET AND DEATH 6/216
11 IF STILLBORN, enter that fact here.
12
AGE
Years
Months. 2 Days
If under 24 hours
Hours
Minutes
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
PlanENTE PRZE ViAI
OTHER
SIGNIFICANT
CONDITIONS
Placenta previa mangemites.
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) M. D. Dr. Michal Century Place of Hurial of C (City or Town) DATE OF BURIAL July 18 1957
7 NAME OF
ADDRESS 19 Couper Se Buah
Received and filed
JUL -1 7 -1953
19
(Registrar)
8 SEX
F
9 COLOR OR RACE
W.
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
10a If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
13 Usual
Occupation :.
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No. Withinog, When
16 BIRTHPLACE (City). (State or country> ES: Jaseph Contendo 17 NAME OF FATHER
18 BIRTHPLACE OF FATHER (City) (State or country)
contar
PARENTS
19 MAIDEN NAME
OF MOTHER
Labora Cassaro
20 BIRTHPLACE OF MOTHER (City) (State or country)
21 Informapt. (Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or cansit permit was issued: Walter S. Bakery (Signature of Agent of Board of Health or other) Healthe Office 7.17.53
(Official Designation)
(Date of Issue of'Permit)
UCTIONS FOR CERTIFICATE giving OF DEATH ot enter than one for each (b) and (c)
does not mean of dying. such lure, asthenia, ns the disease, cations which th.
d conditions, ing rise to the e (a) stating lying cause
tions contrib- death but not the disease or causing death.
Besten 5/3/5 .
Jaren Contardo (If deceased is a married, widowed 29 ashley
(a) Residence. (Usual place of abode)
Length of stay: In place of death ..... .. years ... ...... months.
days, In place of residence ... years
Registered No.
2 FULL NAME ..
ercea woman, give also maiden name.)
tate)
4 I HEREBY CERTIFY,
July 14,
1253
I last saw HEY alive on
350A. .. m.
50M (B)-1-51 903586
1
PERSONAL AND STATISTICAL PARTICULARS
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical Sliced 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: Lars, 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 knowelle and beef, served in the army, navy or marine corps of the United States in any &z
in which it has been engaged. insert in the certificate a recitalto that effect spediffing the war, and shall also certify in such certificate both the primatuunique secondary or imme- diate cause of death as nearly as he can sta "The am neglect to comply with any provision of this section, such physi For the purposes of this section and of sections'for ty six and forty-seven
han forfeit ten dollars. of said chapter one hundred and fourteen, the Rift. chall 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 hundre tp. and the Mexican border service of ninetecn hundred and sixteen JUbintern hundred und 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 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 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 sooncr 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 thercafter furnish for registration any other necessary information which can he 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 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 tn 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 ohservance 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 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 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 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
X
PLACE OF DEATH
i (County) !
(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.
6578158
J(If death occurred in a hospital or institution. St. [ give its NAME instead of street and number)
2 FULL NAME. John J Gallagher
(If deceased is a married, widowed or divorced woman, give also maiden name.)
241 Washington Ave
St.
Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years ..
.months. 1
days. In place of residence
40
.years
.months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July 21, 1953
(Month)
(Day)
(Year)
That I
attended deceased from
4 I HEREBY CERTIFY,
July 20
53
19
to
July 21
19
53
im
I last saw h
alive on
July 21
19
53
death is said to
have occurred on the date stated above, at.
9:05p
m.
INTERVAL BE-
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
78
AGE
Years.
Months.
Days
If under 24 hours
Hours .......
. Minutes
13 Usual
Occupation:
DeputySheriff
(Kind of work done during most of working life)
14 Industry
or Business:
Suffolk County
15 Social Security No.
16 BIRTHPLACE (City) ... Boston ... Mass (State or country)
17 NAME OF
FATHER
John J Gallagher
18 BIRTHPLACE OF
FATHER (City)
Boston Mass
(State or country)
19 MAIDEN NAME
OF MOTHER
Bridget Shannon
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
England
6
Winthrop Com Place of Burial or Cremation
WinthropMass (City or Town)
DATE OF BURIAL
July 24
19
5 321
Informant
(Address)
7 NAME OF
FUNERAL DIRECTOR
MW Kirby
ADDRESS Winthrop Mass
Received and filed
ALIG $ 1.05
.19
......
(Registrar of City or Town where deceased resided)
5
3 wks 1
ANTE Due To CEDENT (b) CAUSES
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Hypertensive .... heart ..
disease
1 yr
Major findings:
Of operations.
Date of operation
Was autopsy performed ?.
.y.e.s
What test confirmed diagnosis?
Autopsy
5 Was disease or injury in any way related to occupation of deceased ?. If so, specify ... (Signed). L R Lezer
(Address)
Date 7/22
'53
19 ...
PARENTS
Wife
A TRUE COPY
arles 21 Mackie
ATTEST
(Registrar of City or Town where death occurred)
DATE FILED
July 24
53
19
(write the word)
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED Married
of DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Mary .... E.Sullivan.
(Give "maiden name of wife in full)
(or) WIFE of
TWEEN ONSET AND DEATH
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) Hemorrhaging gastri ulcer
25M·3-53.909098
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 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.)
A R-302 1
MassGeneral Hospital No.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. (Usual place of abode)
RECEIVLE
( IF
TOW
11.12
13-10
NIE-
RO
AUG-3 AM
DH-VS-5a-15M-52
COPY OF CERTIFICATE OF DEATH STATE OF VERMONT
Certificate No.
159
1. FULL NAME OF DECEASED
(First)
(Middle)
(Last)
William Alexander Pennie
2. DATE OF DEATH
(Month)
(Day)
(Year)
Jul
22
1953
3. PLACE OF DEATH
a. COUNTY
Windham
4. USUAL RESIDENCE (If institution·residence before admission)
a. STATE
b. COUNTY
Suffolk
Mass.
b. CITY OR TOWN (If rural,
please siate)
c. LENGTH OF STAY (In
this place)
Brattleboro
d. NAME OF IIOSPITAL OR INSTITUTION (If not in hos- pital, give street address)
Brattleboro Retreat
d. STREET ADDRESS (If rural, give R. F. D. number) 23 Elmwood Ave
5. SEX
M
W
6. COLOR OR RACE | 7. MARITAL STATUS
(Check one)
913M
Apr 5th 1877-76
If under 1 year
Days
17
Months
3
If under 24 hrs.
Hours
Mins.
10a. USUAL OCCUPATION (Kind of
work done most of working life)
Plumber Ret.
10b. BUSINESS OR
INDUSTRY
11. BIRTHPLACE
Boston Mass.
12. CITIZEN OF WHAT
COUNTRY?
U. S.
13. FATHER'S NAME William Pennie
15. MOTHER'S MAIDEN NAME
Annie Penney
16. MOTHER'S BIRTHPLACE
(Town)
(State or Country)
Scotland
Scotland
17. WAS DECEASED EVER IN U. S. ARMED FORCES? | 18. SOCIAL (Yes, no, unknown) | (Give war & dates of service)
SECURITY NO.
19. INFORMANT'S NAME (Person giving this information) Brattleboro Retreat Rec.
20. I. DISEASE OR CONDITION DIRECTLY LEAD- ING TO DEATH. This does not mean the mode of dying, such as heart failure, asthenia, etc. It means the disease, injury or complications which caused death.
(a) Broncho Pneumonia
DUE TO
(b) Chronic Myocarditis
ANTECEDENT CAUSES. Morbid conditions, if any, giving rise to the above cause (a) stating the under- lying cause last.
DUE TO
(c) Parkinson's Disease
II. OTHER SIGNIFICANT CONDITIONS (Contributing to the death but not related to disease or condition causing it) Chronic Brain Syndrome Associated with Cerebral Arteriosclerosis 21. DATE OF OPERATION | 21a. MAJOR FINDINGS OF OPERATION
22. AUTOPSY
Yes
No to
23a. ACCIDENT, SUICIDE, HOMICIDE (Specify)
23b. PLACE OF INJURY (In home, farm, factory, | 23c. CITY OR TOWN
street, etc.)
COUNTY STATE
23d. TIME OF INJURY
(Month, day, year)
(hour)
23e. INJURY OCCURRED
While at work
Not at work
23f. HOW DID INJURY OCCUR?
24. I hereby certify that I attended the deceased fromMay 13/53 to Jul 22,53
and that death occurred 630 P FÅ, from the cause and on the date stated above.
25a. SIGNATURE N. R. Caldwell
(Degree or Title)
M. D.
25b. ADDRESS
Brattleboro Vt.
25c. DATE SIGNED
Jul 22-1953
(State)
26a. BURIAL, CREMA-
HON, REMOVAL
(Specify)
26b. DATE
July 23 1953 Puritan Lawn
26c. NAME OF CEMETERY OR CREMATORY | 26d. LOCATION (Town or County)
-
Lynnfield Mass. Suffolk
27. DATE REC'D BY TOWN OR CITY CLERK July 25, 1953
28. CLERK'S SIGNATURE Jettie B. Tupper
29. FUNERAL DIRECTOR'S SIGNATURE
ADDRESS
Mitchell-ber Funeral Home
Waldo W. Ker - Owner-Brattleboro.
Asst. Town Clerk
AUG
6 1953
no
Medical Certification
DURATION
14. FATHER'S BIRTHPLACE (Town) (State or Country)
c. CITY OR TOWN (If rural, please state) Winthrop
8. DATE OF BIRTH | 9. AGE (In years
last birthday)
that I last saw deceased alive on
Jul 221. 53
State definitely the cause of death.
Avoid as far as possible all terms classified as "causes ill-defined."
When any item called for cannot be obtained filf in the blank space "unknown."
Write the name of deceased in full; initials only are' not acceptable.
EXTRACTS FROM THE PUBLIC LAWS OF VERMONT
Certificate furnished family ; burial permit. The physician or person filling out the certificate of death, within thirty-six hours after death, shall deliver the same to the family of the deceased, if any, or to the undertaker or per- son who has charge of the body ; and such certificate shall be filed with the person issuing the certificate of permission for burial, entombment or removal obtained by the person who has charge of the body, before such dead body shall be buried, entombed or removed from the town. Whywench certificate of death is so filed, such officer or person shall immediately issue a certificate of permission for burial, entombment or removal of the dead body under legal restrictions and safeguards.
AUG: 6, AM
Unauthorized burial or removal; penalty. A person who buries, entombs, transports or removes the dead body of a human being without the certificate of permission so to do, or in any other manner or at any other time or place than as specified in such certificate, shall be imprisoned not more than one year or fined not more than five hundred dollars nor less than ten dollars, or both.
Use separate form for filing fetal deaths (stillbirths).
These forms may be obtained from the State Health Department, Burlington.
Town Clerk's Office, Brattleboro, Vt., August 1, 1953 I hereby certify that the foregoing is a true copy.
(Town or City Clerk)
DUTY OF TOWN CLERK Vermont Statutes, Revision of 1951
Sec. 219. On the first day of each month, he shall make a certified copy of all births, marriages and deaths filed in his office during the preceding month, except births of illegitimate children, whenever the parents of a child born, or a bride or a groom or a deceased person was a resident in any other town at the time of such birth, marriage or death, and shall transmit such certified copy to the clerk of such other town who shall file the same.
M R-301A 1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
Mayflow
Nursing Home
Winthrop [(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
Charles William Swain e
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
114 Fenway
Boston
St
(If nonresident, give city or town and State)
Length of stay: In place of death years ... 3 . . months. .. days. In place of residence 50 .years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR OR RACE
white
10 SINGLE
MARRIED
WIDOWED
Single
(write the word)
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
april 22.
19:53
to July 23
19 $ 3
I last saw halive on
July 23
19 5 2, death is said to
have occurred on the date stated above, at 10 4 m.
INTERVAL BE-
TWEEN ONSET
11 IF STILLBORN, enter that fact here.
12
AGE90
Years
8.
Months
O
Days
If under 24 hours
.Hours
Minutes
13 Usual
Occupation:
Retired Musician
(Kind of work done during most of working life)
14 Industry
Music
or Business:
15 Social Security No.
none
16 BIRTHPLACE (City) .. Belmont, N.H. (State or country)
17 NAME OF William L.Swaine FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Belmont,N.H.
19 MAIDEN NAME
OF MOTHERnnie E. Leighton
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Belmont, N.H.
6 Mt .. Auburn .... Crematory
Place of Burial or Cremation
(City or Town)
DATE OF BUR
July 25, 1953
19
7 NAME OF
FUNERAL DIRECTOR
J.S.Waterman & Sons
ADDRESS
Boston,Mass.
Received and filed
JUL 241053
19
(Registrar)
2 yr
ANTE
CEDENT (b)
CAUSES
Due To Chiroma nephritis
Due To (c)
OTHER
Diabetes
SIGNIFICANT
CONDITIONS
5 yrs
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?no
If so, specify 7 Salerno
(Signed).
(Address) 175 Pleasant IT Will Date Jaren2/ 1953
M. D.
PARENTS
21 John H. Dawson -- friend (Addr. 60 State St. Boston, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit petmit was issued: Walter A. Bakery (Signature of Agent of Board of Health of other) Thealth fiche 7,24,53
(Official Designation) (Date of Issue of Permity
RUCTIONS FOR . CERTIFICATE
giving OF DEATH not enter than one for each (b) and (c)
does not mean of dying, such ilure, asthenia, ans the disease. ications which 3th.
id conditions. ving rise to the se (a) stating rlying cause
itions contrib- e death but not the disease or causing death.
50M-3-53-909098
No.
39 Grovers Ave .
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. 160
(Was deceased a U. S. War Veteran, { if so specify WAR)
no
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 I
TO DEATH (a)
Elisonia Miocardite
AND DEATH i gr
3 DATE OF
DEATH
July
23
1953
(Usual place of abode)
12 T
EXTRACTS
FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
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