USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1953 > Part 75
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Na 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 burjal 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. ! !
(?) 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
December 15. 1917
DATE OF DISCHARGE
July ... 12, 19.19
RANK, RATING
Corporal
ORGANIZATION AND OUTFIT Supply Co. 326 Quartermaster Corps
SERVICE NUMBER
701815
........
X
SUFFOLK
(County) V
(City or Town) .
No. 736 Washington
St.
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.
9724241
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number) XX
2 FULL NAME
KATHERINE .... L .... CAREY
(If deceased is a married, widowed or divorced woman, give also maiden name.)
3 Lorean Terrace,
St.
Winthrop. ..... Mass.
xx
(If nonresident, give city or town and State)
Length of stay: In place of death.
.years
months 12 .... days. In place of residence
.. years.
.months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Nov am bor
3
1953
(Year)
(Month)
(Day)
That I
attended deceased from
to
11/3., 19 .... 53
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 ... 7.2.Years
Months.
Days
If under 24 hours
Hours ......
.Minutes
13 Usual
Occupation:
retired Nurse
(Kind of work done during most of working life)
14 Industry
or Business:
U.S.Vet .... Adm.Nurso
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Salem
OTHER
SIGNIFICANT
CONDITIONS
Hypertension
6yrs
Major findings:
Of operations.
Date of operation.
Was autopsy performed ?.
What test confirmed diagnosis?
SKG
5 Was disease or injury in any way related to occupation of deceased?
If so, specify.
no
(Signed).
J Doherty
M. D.
(Address)
St. Eliz. Hosp.
Date.
123-
6 Place of Banalyor Cremation Saley, Mass.
DATE OF BURIAL. Nov .6
1953
7 NAME OF
FUNERAL DIRECTOR
J ..... O .! Maloy.
ADDRESS Winthrop, Hass. 19
Received and filed.
NOV 16-1953
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Honora Horgan
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21
Informant
(Address)
...... J.Lester Hourigan
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
Nov 6
.. .
19
53
1
ANTE
CEDENT (b)
CAUSES
farction
Due To myocardial in.
Due To (c)
25m-(b)-11-49-900,475'
PLACE OF DEATH
R-302 1
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time 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.)
8 SEX
9 COLOR OR RACE
(write the word)
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Single
4 I HEREBY CERTIFY,
11/2
19
......
...
I last saw
her
alive on
11/2
1953 death is said to
have occurred on the date stated above, a55. 358
.. m.
INTERVAL BE-
TWEEN ONSET
AND DEATH
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) .... pulmonary edoma
Bdays
13days
Mass
17 NAME OF
FATHER
Timothy Carey
DATE FILED
(Was deceased a
U. S. War Veteran,
ww
I
if so specify WAR)
(a) Residence. No. (Usual place of abode)
DATE OF ENTERING MILITARY SERVICE - 9/21/18
DISCHARGE
1/11/21
RANKRATING
2nd Lt.
ORGANIZATION & OUTFIT
U S Army Nurse Corps
Til
·17:11
6
NOV16
X
PLACE OF DEATH
Suffolk (County)
Cholsca
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Chelsea
(City or town making return)
Registered No.
G21 242
No.Soldiers! Home Hospital
f(If death occurred in a hospital or institution,
St. [ give its NAME instead of street and number)
2 FULL NAME.
Jomas Francis Dennehy
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
374 Ploasant
St.
(If nonresident, give city or town and State)
Length of stay!
Prophet of death ] years 9 months 25 days. In place of residence.
5 years
.. months.
....... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Nov.5.1953
(Month)
(Day)
(Year)
8 SEX
Lalol
9 COLOR OR RACE
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
of DIVORCED i do wed
4 I HEREBY CERTIFY,
That I attended deceased from
1952 ....
to.Nov. 5.
19 .. 53
I last saw h ... .. ]]. alive on.
Nov .4 ..
195 .. , death is said to
have occurred on the date stated above, at 5:55A
.. m.
(or) WIFE of.
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Hypertensive heart
INTERVAL BE- TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE2 Years 7 Months 10
.Days
If under 24 hours
.Hours ....
. . Minutes
13 Usual
Occupation:
P.O.Clork
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No .... none
16 BIRTHPLACE (City)
(State or country)
Cork, Ireland
OTHER
SIGNIFICANT
CONDITIONS
Auricullar fibrillation
Major findings:
Of operations.
Date of operation Was autopsy performedmo
What test confirmed diagnosis? clinical
5 Was disease or injury in any way related to occupation of deceased? If so, specify. (Signed) Ben jamin Goldstein M. D.
(Address) Soldienst Home Dat 7 .5.53 .19
6
Holy Cross Halden , Man City of Town) Place of Burial of Cremation
DATE OF BURIAL Hov.7.1955
19
7 NAME OF
FUNERAL DIRECTOR.
Richard C. Kirby
ADDRESS
Bonnington St. Foot Boston.
Received and filed.
DEC 8 1453
.19
......
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
Iroland
FATHER (City)
(State or country)
19 MAIDEN NAME OF MOTHER Julia Kollihor
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Iroland
21 Hospital Records
Informant.
(Address)
91 Crest Ave. Chelsea Lass
A TRUE COPY ATTEST: Joseph aTyrrell
(Registrar of City or Town where death occurred)
DATE FILED
Nov. 5,1953
..... .19 ...
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
50m-(e)-10-48-24658
ANTE
Due To
CEDENT (b)
CAUSES
2 yrs
10a If married, widowed, or diyorced
HUSBAND of.
Sarah 1. Warren
(Give maiden name of wife in full)
Winthrop, Lass
(Was deceased a
U. S. War Veteran,
( if so, specify WAR)
(Usual place of abode)
Due To
(c)
17 NAME OF
FATHER
Michaol
-
DEC-9.
Enlisted Dec.26,1917 Discharged Dec. 16,1918 Private 1/c Co.A.34d Batt.U.S.Guards 591644
PLACE OF DEATH
Suffolk (County) REVERE
1/12/53
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. 243
Winthrop Community Hospital J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number) No.
2 FULL NAME John B. Faucon
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 144 Bradstreet
Ave. Revere, Mass
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death ........... years 3 months .days. In place of residence .. 40 .... years months. .days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
(Day)
4 I HEREBY CERTIFY,
That I attended deceased from
Supt
4
19
53
1953
I last saw h ww alive on
to ..
6, 195 2, death is said to
have occurred on the date stated above, at.
4:45 P. m.
INTERVAL BE-
DISEASE OR CONDITION
DIRECTLY LEADING J
TO DEATH (a)
Coronary Tambores
.
TWEEN ONSET AND DEATH 2 mo
11 IF STILLBORN, enter that fact here.
12
74
AGE
Years
Months.
Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation:
Cigar Mfg
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No ..
none
16 BIRTHPLACE (City)
(State or country)
Belgium
17 NAME OF
FATHER
Nicolas Faucon
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Belgium
19 MAIDEN NAME
OF MOTHER
Maria Laurent
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Belgium
21 Informant. Mrs . Marguerite Staton Daug (Address) 144 Bradstreet Ave., Revere, Mass
7 NAME OF
FUNERAL DIRECTOR
ADDRESS ....... No .Bennet St. Boston .... Mas.s ..
Received and filed NOV 10 1953 .............. 19.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR OR RACE
(write the word)
8 SEX
male
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDmarried
10a If married, widowed, or divorced
HUSBAND of.
Caroline Cornelissen
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
ANTE
CEDENT (b)
CAUSES
· Caroline Failure
2 molho
5 jrs
OTHER
SIGNIFICANT
CONDITIONS
?
Major findings:
Of operations.
Date of operation
... Was autopsy performed?
E. K. G.
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
(Address) 17 Huiles Com
M. D.
Date 11/6 .19 .... 3 ..
6 Holy Cross
Place of Burial or Cremation
Malden ...... Mas.s. (City or Town)
DATE OF BURIAL ......
Nov ...... 9,
1953.
Michael & Forcella
I HEREBY CERTIFY that a satisfactory standandi certificate of death was filed with me BEFORE the burial or transit permit was issued: Malter A. Lakers (Signature of Agent of Board of Health of other)
11. 9. 53 Talatthe Office (Official Designation) (Date of Issue of Permit) A
CTIONS R ERTIFICATE ving F DEATH enter an one or each and (c)
es not mean dying, such re, asthenia, the disease, ions which
conditions. grise to the (a) stating ing cause
ns contrib- eath but not disease or sing death.
50M-5-52-907046
R-301A 1
Winthrop (City or Town)
Registered No.
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, ( if so specify WAR) No
nov.
6
1453
(Year)
1
Due To typestensmi
(c)
BRUSSELS
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.
1
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 . Chap. 114, Sec. 46, G. L., (Tercentenary Edition). 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 RULES OF PRACTICE relief expedition and the Philippine insurrection, which shall. for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and The fulfillment of the purpose of these laws calls for the observance of the follow- ing rules.of practice: ninety-eight and July fourth, nineteen hundred and two, and the Mexican border (1) Attending physicians will certify to such deaths only as those of persons service of nineteen hundred and sixteen and nineteen hundred and seventeen Tito whom they have given bedside care during a last illness from disease unrelated G. L. Chap. 46. Sec. 10.
1
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 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 C '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.
I 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 1 sol 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 he held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made.
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 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
Middlesex ...
(County)
Cambridge
....
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
Cambridge (City or town making return)
Registered No.
1539
244
[(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.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
-
(a) Residence. No. 19 Moore St.
St.
Winthrop
(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
3 DATE OF
DEATH
November
6,
1953
(Month)
(Day)
(Year)
8 SEX
Female
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED Married
4 I HEREBY CERTIFY.
That I attended deceased from
Q.ct ...... 16
19 ..... 5.3.
to.
Nov. 6
19 ... 53 ..
I last saw h .... er .... alive on
Nov. 5, 1953, death is said to
(or) WIFE of
George E. Fitzgerald
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Metastatic cancer.
stomach
INTERVAL BE- TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE.70
11
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:
At home
15 Social Security No.
none
16 BIRTHPLACE (City)
(State or country)
Germany
17 NAME OF
FATHER
Herman L. Place
18 BIRTHPLACE OF
FATHER (City).
Germany
(State or country)
19 MAIDEN NAMWilhemenia Woloschnewsky OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
Germany.
(State or country)
Ralph Knight
21
Informant.
(Address)
38 Ascutney .... St ...... Windsor ..... V.t ..
A TRUE COPY
Frederick. H. R.A.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
November 6, 1953
.. 19.
.....
1.1V
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 .(B)-11-51-905807
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Nov. 9, 1953
19
7 NAME OF
FUNERAL DIRECTOR
Joseph S. Waterman
ADDRESS
495 Comm. Av. Boston
Received and filed
DEC 3 1953
19
(Registrar of City or Town where deceased resided)
PARENTS
5 Was disease or injury in any way related to occupation of deceased?no
If so, specify .......
George B. Smithy
M. D.
(Signed) ...
HolyGhost Hospt
Date 11/6
53
(Address) ..
Hit. Auburn Crem.
9/53
Date of operation.
.. Was autopsy performed? yes
What test confirmed diagnosis?
Specimen
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
have occurred on the date stated above, at.
12.35A
..... m.
unkn
ANTE
Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations
Inop. cancer stomach
MIS.
R-302 1
Holy Ghost Hospital No.
Emma Fitzgerald
....
Cambridge
(write the word)
TOM
6
0
DEC-3
I C I
C
S
וח
T 1
€
(
C 1 1 1 1
( 1
( 1 1 € c C 1 T I (
R-302
PLACE OF DEATH
I SITEBOCK
(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. ...
9392
245
J (If death occurred in a hospital or institution, St ) give its NAME instead of street and number) XXX
2 FULL NAME FRANK CAMPBELL
(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)
33 Banks
St.
... Anthrop
(If nonresident, give tity oft
wn and State)
Length of stay: In place of death.
.. years.
months.
....... days. In place of residence ... g. years
.months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
November
7
1953
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That WEttended deceased from
10/31
19.
to
11/7
19.53
Wol last saw h ... 1.m .... alive on
11/7
153 ... death is said to
have occurred on the date stated above, at.5 .: 30a.
.. m.
INTERVAL BE-
TWEEN ONSET
AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE
92 Years
Months.
27
.Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation:
RKitapdone during most of working life)
14 Industry
or Business:
Portable
15 Social Security No ..
16 BIRTHPLACE (City) ....
(State or country)
Nova Scotia
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