USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1953 > Part 64
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SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE
RANK, RATING.
ORGANIZATION AND OUTFIT
SERVICE NUMBER
X
PLACE OF DEATH
1
SUFFOLK
BO(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.
8207 205
Mass General Hospital
J(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.) 45 Highland 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.
.. months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Sept 19, 1953
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
Aug 20
53
That I attended deceased from
Sep 19
19
53
er
19
to.
Sep 19
53
...
19.
death is said to
have occurred on the date stated above, at
m.
INTERVAL BE- TWEEN ONSET AND BEATN
DISEASE OR CONDITIONrdig vascular DIRECTLY LEADINGease due to
DEAHexbionof the losser
circulatory d sease
18 mo $
42
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. Russia
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
Benjamin Cohen
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Rose --
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
Place of Burial or Cremation
Sep 2 City or Town)
53 19
21 Informant (Address)
A TRUE COPY
Charles & Manche
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Sep 22
53
19
VIV
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
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,
25M-3-53-909098
7 NAME OF
FUNERAL DIRECTOR
B Birnbach
ADDRESS Boston Mass
Received and filed. 19
(Registrar of City or Town where deceased resided)
8 SEX
Female
9 COLOR OR RACE
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
Married
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Bon gaderrame dofaflick
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
Hypertensive cardio
ANTE
Due Vascular disease
CEDENT (b). CAUSED structive emphysema
yrs yrs
Due To
Saccular bronchie-
(c)
ctasis of right
upper lobe
yrs
OTHER
SIGNIFICANT
CONDITIONS
Bronchoscopy 9/13/53
Major findings:
Of operations.
Tracheotomy9/19/53
yes
Date of operation.
.. Was autopsy performed?
Autopsy
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? no
If so, specify.
JA Pittman
(Signed) MGH
(Address)., Leb Crawford St Cem 6
Date ..
9/19
19.
Boston
DATE OF BURIAL
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 -
M R-302 1
No.
Rose Goralnick
(Was deceased a
U. S. War Veteran,
if so specify, WAR)
Winthrop
mass
(a) Residence.
No.
(Usual place of abode)
30
I last saw h
alive on
4.50
Housewife
PARENTS
Ilusband
RECEIVE
TOW
1.7
HROP
SEP28
AM
X
PLACE OF DEATH
SUFFOLK (County) 1
(City or Town)
Mass General Hosp No.
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
8265
206
(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.)
70 Moore St
St.
Winthrop Mass
(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
Sep 19, 1953
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.) Fracture of skull & laceration of brain. Accidental, Struck by motor Car
9 SEX
emale
10 COLOR OR RACE
White
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
Single
11a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
2
5
27
AGE
Years
Months.
Days
If under 24 hours
Hours .....
Minutes
14 Usual
Occupation :
(Kind of work done during most of working life)
15 Industry or Business:
16 Social Security No.
17 BIRTHPLACE (City) .... Boston Mass (State or country)
18 NAME OF
FATHER
Herbert J Lowney
PARENTS
19 BIRTHPLACE OF
FATHER (City).
Boston Mass
(State or country)
20 MAIDEN NAME
OF MOTHER
Helen E Day
21 BIRTHPLACE OF
MOTHER (City)
Cambridge Mass
(State or country)
22 Informant (Address)
Father
ATTEST:
COPY. Parles & Mackie
(Registrar of City or Town where death occurred)
Received and filed. 19
(Registrar of City or Town where deceased resided)
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.) of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided as soon as possible
25M-3-52-907046
6 Was disease or injury in any way related to occupation of deceased? ....
If so, specify
(Signed)
M A Luongo
(Address) 25 Shattuck St
Date
at 8/20
M. D. 53 19 ........
Holy Cross Cem
Malden Mass
Place of Burial, or Cremation.
DATE OF BURIAL
Sep 22
(City or Town) 53
8 NAME OF
FUNERAL DIRECTOR
J C Kelly
ADDRESS
Boston Mass
.....
5 Accident, suicide, or homicide (specify).
Accident
Date and hour of injury.
Sep 19
.19 ..
53
Where did
Winthrop Mass
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Publichighway
(Specify type of place)
Injury
Manner oPedestrian Struck by motor
(How did injury occur?)
Nature ofcar Injury
While at work?
.Was autopsy performed?
....
no
M R-305 -
Geraldine Lowney
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
(Usual place of abode)
(write the word)
DATE FILED
Sep ..... 23
1953
RECEIVE".
TO!
.1
8
SEP28 AM
PLACE OF DEATH
Suffolk (County)
R-301A 1 Winthrop (City or Town)
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.
207
Winthrop Community Hospital No.
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)
NO.
(a) Residence. No. 39 Grovers Avenue
(Usual place of abode)
Length of stay: In place of death .years. months 1 days. In place of residence. 3
..........
St.
(If nonresident, give city or town and State)
.years
.. months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
September 20 1953
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
august 20 1953
150
to ... A
Agat 20
I last saw her alive on
Sept
20
19.53, death is said to
have occurred on the date stated above, at.
8:35 pm.
INTERVAL BE-
DISEASE OR CONDITION
DIRECTL
Cerebral.
TWEEN ONSET AND DEATH 10 hrs.
TO DEATH (a)
Isemontage
ANTE
CEDENT
(b)
Due To
generalized
CAUSES
arteriosclerosis
Due To
(c)
Uremia
OTHER
SIGNIFICANT
CONDITIONS
une
Major findings:
Of operations.
none
Date of operation
Was autopsy performed Lo
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? Lo If so, specify. (Signed) kaut & Chans la 00 M. D. (Address) 1562 Sebile Eur Par Date 9/21/5319
Forrest Hill Cemetery Jamaica
6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL ... September ..... 23.1.953 19
7 NAME OF
FUNERAL DIRECTOR
achalk March
ADDRESS
174 Winthrop St, Winthrop,
Received and filed. 19
(Registrar)
11 IF STILLBORN, enter that fact here.
12
AGE .... 7.5.Years
6 Months 26 . Days
If under 24 hours
Hours
. .. Minutes
13 Usual
Occupation :.
retired housekeeper
(Kind of work done during most of working life)
14 Industry
or Business:
own ... home
15 Social Security No .. none
16 BIRTHPLACE (City)
(State or country)
Prince Edward Island
17 NAME OF
FATHER
Thomas Hardy
PARENTS
18 BIRTHPLACE OF
FATHER (City)
York
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Richards
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
unable to obtain
21
Informant
(Address)
14 Egleton Park, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Mass. Walter A. Bakery.
(Signature of Agent of Board of Health or other)
9.22.53
(Official Designation) (Date of Issue of Permit)
X
UCTIONS FOR CERTIFICATE
giving OF DEATH t enter than one for each b) and (c)
does not mean f dying, such ure, asthenia, ns the disease, ations which h.
conditions. ng rise to the (a) stating ying cause
ions contrib- death but not e disease or using death.
SOM-10-52-908091
2 FULL NAME
Martha Elsie Brooks
(If deceased is a married, widowed or divorced woman, give also maiden name.)
8 SEX
female
white
9 COLOR OR RACE
10 SINGLE
(write the word)
MARRIED widowed
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
John Robert. Brooks
(Husband's name in full)
2 years
5 hrs.
York Village
Ernest .... E.Hardy.
Registered No.
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 (leath 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 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 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 perinit. 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 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 regent 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 uinclude 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 het 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
SUFFOLK BOSTON
(City or Town)
No. 45 Townsend
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.
8317208
J(If death occurred in a hospital or institution, St. Į give its NAME instead of street and number)
2 FULL NAME.
(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. (Usual place of abode)
38 Trident Ave.,
XXXX.
Winthrop, Mass
(If nonresident, give city or town and State)
Length of stay: In place of death
.years
2
months
22
days. In place of residence
.years.
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
September
22
1953
DEATH
(Month)
(Day)
(Year)
8 SEX
F
9 COLOR OR RACE
W
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
4 I HEREBY CERTIFY,
7/8
19
to
9/22
1953
I last saw h.
er
alive on
9/22
,53
19
death is said to
10a
If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Jacob Cohen
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
acute pulmonary
edema
24hrs
12 55
AGE
Years.
Months.
.Days
If under 24 hours
Hours .......
.Minutes
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry
Own home
or Business:
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
England
OTHER
SIGNIFICANT
CONDITIONS
auricular fibrillation
-7mos
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? MO
If so, specify.
(Signed) .... ... Nussbaum
(Address) Boston
M. D
RumanianCom.
(City or Town)
Place of Burial or Cremation DATE OF BURIAL.
Sep 23
53
19
7 NAME OF
FUNERAL DIRECTOR
H J Torf
ADDRESS
Chelsea, Mass.
Received and filed.
OCT 5- 1953
19
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Rebecca -
.-
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21
Informant
(Address)
J Cohen
A TRUE COPY Mances & Mack.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Sep 25
.19 ...
.19
53
M.S
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.)
25M-3-53-909098
6
Danvers
11 IF STILLBORN, enter that fact here.
TWEEN ONSET AND DEATH
ANTE
CEDENT (b)
CAUSES
failure
5yrs.
Due To
rheumatic heart
(c)
disease
50yrs
Housewife
Due To
congestive cardiac
That I
attended deceased from
(write the word)
have occurred on the date stated above, at.
7:35р.
m.
INTERVAL BE-
PEARL COHEN
M R-302 1
17 NAME OF
FATHER
Louis Lightman
Date.
9/221.53
NECEIVI
٠٠٠٠٠
٢٠٠
6
OCT-5
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
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. 209
.. St. [ give its NAME instead of street and number) No. Winthrop Community Hospital
2 FULL NAME Agnes L. Digou (Dawson )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
675 Chestnut Hill Avenue
St. .
Brookline
(If nonresident, give city or town and State)
Length of stay: In place of death years months 3 .days. In place of residence 2 years months .days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
September .22
(Month)
(Day)
1953.
(Year)
Female
9 COLOR OR RACE
White
MARRIED
WIDOWED
or DIVORCED Widowed
4 I HEREBY CERTIFY,
That I attended deceased from
Jan ... l.,
1953 ..
to .
Sept. 22,
155.3.
I last saw h .er. alive on
September 19. 5 3death is said to
have occurred on the date stated above, at 6:20 AM INTERVAL BE-
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) Acute pulmonary edema
TWEEN OKSET AND DEATH
1 day
CEDENT (b)
CAUSES
Due To
Chronic nephritis
(c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
none
Date of operation
none
Was autopsy performed?
no
What test confirmed diagnosis@.linical ... findings.
11 IF STILLBORN, enter that fact here.
12
AGE 70 Years
8. Months 29
Days
If under 24 hours
Hours . .. Minutes
13 Usual
1 yr.
Occupation:
At home
(Kind of work done during most of working life)
14 Industry
or Business:
Housewife
15 Social Security No.
None
16 BIRTHPLACE (City) .
(State or country)
Mass
17 NAME OF
FATHER
Michael Dawson
PARENTS
18 BIRTHPLACE OF
Ireland
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Mary Cummiskey
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21
Miss Mary C. Digou-daughter
675 Chestnut Hill Ave ..
I HEREBY CERTIFY that a satisfactory standardBribeklartevas filed with me BEFORE the burial or transit permit was issued. Walter . Frakes (Signature of Agent of Board of Health or other) The althe office 9.23.53
(Official Designation
(Date of Issue of Permit)
K
A R-301A 1
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
does not mean of dying, such ilure, asthenia, . ans the disease, cations which th.
id conditions. ing rise to the se (a) Stating rlying cause
itions contrib- e death but not the disease or causing death.
50m-(b)-11-49-900,560
.St. Johns
Cemetery, Worcester
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL . September 26th
1953
7 NAME OF
Richard C. Kirby
ADDRESS17 Bennington St., E. Boston
Received and filed
SEP 2 3-1953
19
(Registrar)
8 SEX
J(If death occurred in a hospital or institution,
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran.
if so specify WAR)
No
(a) Residence. No. (Usual place of abode)
10 SINGLE
(write the word)
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Freeman T. Digou.
(Husband's name in full)
ANTE
Due To
Chronic myocarditis
1 yr.
Worcester
5 Was diseasefor injury in any way related to occupation of deceased?
If so, special It Selement
M. D.
(Signed)
(Address) 19 Prywatne 88: 263 Date 9/22
1953
BROCKline 14/5/53
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.
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