USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1953 > Part 89
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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 transnuit 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 ibrought 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 forin of injury.
(2) Board of Health physicians will certify to such deathsonly as those of persons cho. Uhough 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
1
NON- RESIDENT
..
ARIZONA STATE DEPARTMENT OF HEALTH DIVISION OF VITAL STATISTICS
STATE FILE NO.
CERTIFICATE OF DEATH
REGISTRAR'S NO.
123
1. PLACE OF DEATH
A. COUNTY
Maricopa
B. LENGTH OF STAY LIN THIS TOWN IN ARIZONA 25 mths.2 0 IN CITY LIMITS
7th
2. USUAL RESIDENCE A. STATE Mass.
(WHERE DECEASED LIVED.
IF INSTITUTIONI RESIDENCE BEFORE ADMISSION)
B. COUNTY
C. CITY
OR
TOWN
Phoenix
OUTSIDE CITY LIMITS
C. CITY
OR
TOWN
Winthrop
IN CITT LIMITS
D. FULL NAME OF
HOSPITAL OR
INSTITUTION 800
Hi hland ive
B.
(MIDDLE)
C. ( LAST) STANFIELD
4. SEX
5. COLOR OR RACE
IF UNDER 24 HRS. HOURS MIN.
9A. USUAL OCCUPATION (GIVE KIND WORK DURING MOST OF LIFE EVEN IF RETIRE Housewi
9B. KIND OF BUSI - NESS OR INDUSTRY
10. BIRTHPLACE (STATE
OR FOREIGN COUNTRY1
England
11. CITIZEN OF WHAT
COUNTRY ?
U ......
12. WAS DECEASED EVER IN U. S. ARMED FORCES ? (YES. NO, OR UNKNOWN]| ( IF YES. WAR OR DATES OF SERVICE) NO
13. SOCIAL SECURITY
NO.
Non
14A. FATHER'S NAME
Thomas TOPL Y
14B. BIRTHPLACE
ISTATE OR COUNTRY1
england
ISA. MOTHER'S MAIDEN NAME
Unknown
1SB. BIRTHPLACE
(STATE OR COUNTRY)
16. INFORMANT'S SIGNATURE
Mrs. George WINGS tonY
ADDRESS
fdaughter)
17. DATE
OF
DEATH
October
( MONTH)
(DAY)
22,
(YEAR)' 1 53
MEDICAL CERTIFICATION
INTERVAL BETWEEN ONSET AND DEATH
18. CAUSE OF DEATH 1 ENTER ONLY ONE CAUSE PER LINE FOR (A), (B), (C). #THIS DOES NOT MEAN THE MODE OF DYING, SUCH AS HEART FAILURE, ASTHENIA. ETC. IT MEANS THE DISEASE. INJURY, OR COMPLICATION WHICH CAUSED DEATH.
I. DISEASE OR CONDITION DIRECTLY LEADING TO DEATH+
(A)
Ciberently arteno peletorre ##heart disease- embalmed
II. OTHER SIGNIFICANT CONDITIONS CONDITIONS CONTRIBUTING TO THE DEATH BUT NOT RELATING TO THE DISEASE OR CONDITION CAUSING DEATH.
Body
PLACE DISEASE CONTRACTED. 19A. DATE OF OPERATION 19B. MAJOR FINDINGS OF OPERATION
20. AUTOPSY ? YES
NO DX
19 53 To Uct. 22 19 53 TO
THAT L LAST SAW THE DECEASED
ZZA SIGNATURE
London
( SPECIFY)
23B. PLACE OF INJURY (E.G., IN OR ABOUT HOME, FARM, FACTORT. STREET, OFFICE BLDG., ETC.)
23C. (CITT OR TOWN) ( COUNTT ] BIS ATE)
PZ3A. ACCIDENT
SUICIDE
HOMICIDE
NATURAL CAUSE
(MONTH)
(DAY) (YEAR)
( NOUR) M
23E. INJURY OCCURRED | 23F. HOW DID INJURY OCCUR ?
WHILE AT
NOT WHILE
WORK
AT WORK O
24A. CORONER'S SIGNATURE
24C. DATE SIGNED 24B. ADDRESS Court House; Phoenix, AriNet. 2, 105.
25A. BURIAL O
CREMATION
2SB. DATE
0
REMOVAL Duct. 24, 195B
25C. NAME OF CEMETERY OR CREMATORY
2SD. LOCATION (CITY, TOWN, OR COUNTY ] [ STATE) South Manchester, Conn.
26A. DATE REC. BY LOCAL REG. 10/22/53
25A. FUNERAL DIRECTOR'S SIGNATURE Frete. There
278 ADDRESS 314 Jest Monroe St Phoenix, Arizona
FORM VS-2 REV. G-1-53
- AMPCO 703SS
Grimsh. w ortu ry
(Registrar of City or Town where death occurred)
Received and filed.
19
(Registrar of City or Town where deceased resided)
DATE FILED
19
S
.....
.....
I HEREBY CERTIFY THAT I ATTENDED THE DECEASED FROM
53
19
AND THAT DEATH OCCURRED-WT. ( DEGREE OR TITLE)
L
22B. ADDRESS
22C. DATE SIGNED Oct. 22,05
23D. TIME
OF
INJURY
FUNERAL DIRECTOR AND REGISTRAR
A. (FIRST)
D. STREET ADDRESS 60 Sagamore Aver ue
(IF RURAL, GIVE LOCATION).
3. NAME OF
DECEASED
(TYPE OR PRINT)
6B. NAME OF SPOUSE
Mar ot
7. DATE OF BIRTH
MONTN
DAY
Alle of
7
YEAR
1869
8. AGE ( IN YEARS | IF UNDER I YEAR LAST BIRTHDAT) 84 MONTHS DAYS
white
6A. MARRIED, NEVER MARRIED. WIDOWED, DIVORCE'D (SPECIFY) linow
at home
UHAT
......
rd)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY
287
BIRTH NO.
OUTSIDE CITY LIMITS
( IF NOT IN HOSPITAL OR INSTITUTION. GIVE STREET ADDRESS OR LOCATIONI
26B. REGISTRAR'S SIGNATURE
I. FROM THE CAUSES AND ON THE DATE STATE: XDOVE.
ANTECEDENT CAUSES MORBID CONDITIONS, IF ANY. GIVING RISE TO THE ABOVE CAUSE (A) BTATING THE UN-
DERLTING CAUSE LAST.
X
Essex
(County)
Danvers
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Danvers
(City or town making return)
Registered No.
28S.
No. Danvers State Hospital Hathorne Mary E. Batten (Goodrich)
J(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
(Was deceased a U. S. War Veteran,
Winthrolf so specify WAR)
(a) Residence. No.
(Usual place of abode)
(If nonresident, give city or town and State)
months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
December
15,
1953
(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.)
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Unknown)
.. Batten
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AGE.9.3.
Years
Months.
Days
If under 24 hours
Hours ........ Minutes
14 Usual
Occupation 1.
Unable to work
(Kind of work done during most of working life)
15 Industry or Business:
16 Social Security No.
17 BIRTHPLACE (City)
(State or country)
London
England
18 NAME OF
FATHER
Thomas Goodrich
PARENTS
19 BIRTHPLACE OF
FATHER (City)
(State or country)
England
20 MAIDEN NAME OF MOTHER Emma Hi gins
21 BIRTHPLACE OF MOTHER (City) (State or country) England
22
Informant ...
Mary .......... Sheehan
(Address)
Hathorne, Mass,
ATTEST:
Anthus W Say
(Registrar of City or Town where death occurred)
December
21
53
DATE FILED
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Female
10 COLOR OR RACE|
White
11 SINGLE
MARRIED
WIDOWED.15
or DIVORCEDd owed
Arteriosclerosis General Senile Debility
5 Accident, suicide, or homicide (specify).
Date and hour of injury. 19
Where did Injury occur? (City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public place?
Manner of
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed?
Yes
6 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) Ralph .... P .. .... McCarthy M. D.
(Address) Peabody Mass. 12/16/1953
7 Wildwood Cemetery Wincheste
Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL December 18
1952.
8 NAME OF
FUNERAL DIRECTOR
Boston, Mass.
J. S. Waterman & Sons, In& FRUE COPY.
ADDRESS
Received and filed.
3HK.13.054
19
11.5.
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-(h)-10-48-24658
PLACE OF DEATH
R-305 1
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.) 125 Cliff Ave.
St.
Length of stay: In place of death. .years. 1 months. days. In place of residence .. .years.
(write the word)
19
X
(Specify type of place)
JANIS
X PLACE OF DEATH
NORFOLK
(County) BROOKLINE (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BROOKLINVZ (City or town making return)
Registered No. 917 283
No. Allerton Hospital
........
J(If death occurred in a hospital or institution. St. [ give its NAME instead of street and number)
2 FULL NAME. Isaac Katz
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 26 Buchanan Street
St.
Winthrop ...
Massachusetts
(If nonresident, give city or town and State)
(Usual place of abode)
Length of stay: In place of death.
years.
.months
7 days.
In place of residence.
.. years.
6.months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
December
16
1953
(Month)
(Day)
(Year)
8 SEX
male
9 COLOR OR RACE
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
widowed
4 I HEREBY CERTIFY,
That I attended deceased from
December 9. 19 .. 53 .... to December 16 .... 19.5.3.
I last saw him alive on December 15, 19.53 death is said to have occurred on the date stated above, at 9:25 a. m. INTERVAL BE- DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) Multiple Myeloma TWEEN ONSET AND DEATH 2 yrs
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation.
Was autopsy performed?
ves
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? ..... no.
If so, specify.
Henry Baker
(Signed)
183. Beacon St
M. D.
(Address)
Boston, Mass.
Date Dec .... 16 ... 195.3 ....
6 Workmen's Circle Cemetery, Melrose, Mass. Place of Burial or Cremation (City or Town)
DATE OF BURIAL
December .... 17
19.53
7 NAME OF
FUNERAL DIRECTOR
H ....... J ...... Tarf
ADDRESS 15.1 ... Washington ... Av ... ,Chelsea., .... Mas.s.
Received and filed.
JAN 13 1954.
19
(Registrar of City or Town where deceased resided)
11 IF STILLBORN, enter that fact here.
12
AGE .. 69 ... Years
Months.
Days
If under 24 hours
Hours ....
Minutes
13 Usual
Occupation :
Retired Storekeeper
(Kind of work done during most of working life)
14 Industry
or Business:
Retail
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Morton Katz
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Cannot be learned
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Poland
Norman Katz
21
Informant
(Address)
127 Grove St., Chelsea, Mass.
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
19
DATE FILED
December 18
53
X
10a If married, widowed, or divorced
HUSBAND of ..
Anna Glass
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
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-302 to the clerk of the city or town in which the deceased resided as soon as possible
50m-(e)-10-48-24658
I R-302 1
(Was deceased a
U. S. War Veteran,
if so specify WAR)
no
JAN18
X
PLACE OF DEATH
Suffolk (County) Chelsea
(City or Town) Chelsea Soldiors' Home No.
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
2
Chelsea
(City or town making return) 704
Registered No.
230
William Richter
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
85 Freemont st.
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death .years. 7
10
60
(If nonresident, give city or town and State)
months. days. In place of residence .years. months .days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
Dec . 10,1353
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.) Cerebral thrombosis.Gen.Arterio
sclerosis. Arterio sclerose heart disease. Old fracture Rt. Forul.
5 Accident, suicide, or homicide (specify)
Date and hour of injury. 19
Where did Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public place?
Manner of
Injury
(How did injury occur?)
Nature of
Injury
While at work?
.Was autopsy performed?
6 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
n. J. Brickloy
(Address) Boston, dass. Date.
19/16/85
Winthrop Com., Winthrop, wass
7 Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL vec. 10, 1953 19
8 NAME OF Maurice .Kiedy
FUNERAL DIRECTOR Anthrop St.Winthrop ADDRESS WAN 12 1954
Received and filed 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
liale
10 COLOR OR RACE
White
11 SINGLE
(write the word)
MARRIED? WIDOWEDMarried or DIVORCED
11a If married, widowed, or divoLedes
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 76
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: cannot be learned
16 Social Security No ...
17 BIRTHPLACE (City) ..
(State or country)
Jersey .... City., N. J.
18 NAME OF FATHER
Herman
19 BIRTHPLACE OF Barden Barden, Germany FATHER (City) (State or country)
20 MAIDEN NAME OF MOTHERannot' be learnod-Glintz
21 BIRTHPLACE OF MOTHER (City) (State or country)
Germany
22 Any Richter (wife) Informant .moment . t. Inthrop, Hass. (Address)
A TRUE COPY. Joseph aTurrell
... ATTEST:
(Re)
(Registrar of City or Town where death occurred)
DATE FILED
Dec.18,1953
19
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-(h)-10-48-24658
1,5.
[ R-305 1
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
........
SA
(Was deceased a U. S. War Veteran,
Winthro f solspecify WAR)
St.
Trainman
Railroad
(Specify type of place)
no
PARENTS
f
JAN12
Enlisted April 22,1898 Discharged Apr. 21,1901 Private 76th Co.Coast Artillery
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 after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.)
X
PLACE OF DEATH
Suffolk (County)
Chelsea
(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.
705 291
J (If death occurred in a hospital or institution. St. [ give its NAME instead of street and number)
2 FULL NAME. Taby For Toples (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. 10Neptune .... Ave St.
(Usual place of abode)
(If nonresident, give "city or town and State)
Length of stay: In place of death ...
.months.
.days. In place of residence.
.....
.years ..
......
.months ....
.......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Ma.le
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDin -le
(write the word)
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I
attended deceased from
19
...
to
19
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. stillborn
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)
Chel Le
17 NAME OF
FATHER
Robert H.
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) ..
D.M.Shook
M. D.
(Address)}.
Date:0/18/519
6 7.7: Place of Burial or Cremation! ? TYBrett (City of Town)
DATE OF BURIAL. Dec. 12, 1955
19
7 NAME OF
FUNERAL DIRECTOR.
J. Vincent Hurray
ADDRESS ... 262
Received and filed.
19
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Columbus, Ohio
19 MAIDEN NAME
OF MOTHER
Audre: June Norris
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Columbus, Ohio
21 Ing Robert I Pooley
Informant.
(Address)
70
Atune Ave, Mintlpop
A TRUE COPY
ATTEST:
CR
Joseph atTurrell
(Registrar of City or Town where death occurred)
DATE FILED
Dec.18,1953
.19 ..
X
I last saw h ..
......
alive on
19
death is said to
have occurred on the date stated above, at 10 Am
m.
INTERVAL BE- TWEEN ONSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
stillbirth
ANTE
Due To
CEDENT (b) ....... Abruptio placenta.
CAUSES
Due To
(c)
Anencephalus
OTHER
SIGNIFICANT
CONDITIONS
Prematurity.
50m-(e)-10-48-24658
I R-302 1
3 DATE OF
DEATH
De.c ... 16.,19.53
...
Mintiron Man
JANLA
F
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-302 to the clerk of the city or town in which the deceased resided as soon as possible
PLACE OF DEATH
Middlesex (County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Waltham
(City or town making return) 676
Registered No.
292
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
Patrick McIntosh
(If deceased is a married, widowed or divorced woman, give also maiden name.)
38 Ruvere
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
December
19,
1953
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That_
attended deceased from
Dec 19
1953
Dec 19
53
19
I last saw
Im
Dec 19
53
death is said to
have occurred on the date stated above. at
m.
INTERVAL BE-
TWEEN ONSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
emmaturity with brain
TO DEATH
(a).
hemorrhage.
ANTE Due To CEDENT (b) CAUSES
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings: Of operations
Date of operation
.. Was autopsy performed?
JOS
What test confirmed diagnosis?
autopsy
no
12-21 - M53
(Address) ..
Post con., Ft. Devons, Ayer
6
Place of Burial or Cremation
December 22
53
19
21
Informant ..
(Address)
A TRUE COPY.
ATTEST:
(Registrar of Qity or Town where death occurred)
Received and filed
KAN 13 1954
19
(Registrar of City or Town where deceased resided)
8 SEX
male
9 COLOR OR RACE
unite
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
single
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
Years
Months.
Days
hf under 23 Bours
Hours
Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No. waltham
16 BIRTHPLACE (City)
(State or country)
17 NAME OF Gerald S. McIntosh FATHER
18 BIRTHPLACE OFNOVA Scotia
FATHER (City)
(State or country)
Canada
19 MAIDEN NAME,Illian E. Oakes OF MOTHER
20 BIRTHPLACE OF
Boston
MOTHER (City)
(State or country)
Gend S. McIntosh
Winthrop; Hass.
7 NAME OF
FUNERAL DIRECTOR
Telmont, Mass
ADDRESS
(City or Town)
DATE OF BURIAL
5 Was disease or injury in any way related to occupation of deceased?
If so, specify. M. Ludwig
(Signed) .......
Wattham, Mass:
.. Date
PARENTS
50m-(e)-10-48-24658
R-302 1 Waltham
(City or Town) Murphy Army Hospital No.
.........
(Was deceased a
U. S. War Veteran,
No
Winthrop,
if so specify WAR)
(a) Residence. No. (Usual place of abode)
2 FULL NAME
W. J. Cox
DATE FILED
December 29
53
19
alive on
10:10PM
JAN1G
PLACE OF DEATH
Essex (County)
Lynn
(City or Town)
No. Lynn Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Lynn
(City or town making return)
293
Registered No.
J(If death occurred in a hospital or institution,
St. [ give its NAME instead of street and number)
2 FULL NAME.
Alma Avery
( Anderson.)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran.
if so specify WAR).
9} Washington
Winthrop
45
(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.
PERSONAL AND STATISTICAL PARTICULARS
Female
10 COMPRARERACE
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
MafFred
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof Muletstatore (IfarinetusinSved late Liybs and extremities with bilateral hemo
11a If married, widowed, or divorced
HUSBAND of.
(or) WIFE of.
(Husband's name in full)
12 IF ST
7G-LBORN enter that fact here.
13
AGE
Years
Months.
„Days
If under 24 hours
Hours
Minutes
14 Usual
Occupation 1 ..
NOidof work done during most of working life)
15 Industry
or Business:
None
16 Social Security No.
Louisville
17 BIRTHPLACE (City).
(State or country)
John Anderson
18 NAME OF
FATHER
Sweden
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Pauline Hageman
21 BIRTHPLACE OF
MOTHER (City)
(State or Dandel Avery
22
Informant
(Address)
JaMERSE LOPY.Dumas, M.D.
ATTEST:
Commissioneregistrar of fity or Town where death ogcurred)
DATE FILED
C
L
(a) Residence.
No.
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
December 27, 1953
DEATH
(Month)
(Day)
(Year)
thorax and hemopneumonia. Con-
tusion of brain
Accidental.
Auto accident.
Accident
Date and hour of injury Saugus ,Mass.
19
Where did
Injury occur?
(City or town and State)
Manner of
Nature of
While at work?
Was autopsy performed?
If so, spedit
Hugh F. Broderick
(Signed)
Swamp., Mass.
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
Injury
No
Yes
25m-(h)-10-48-24658
7
Place of Burial, or Cremation.
.Dec ........ 3.1.
.5.3.
(City or Town)
DATE OF BURIAL Roy .... ... Peeman 19
FUNERALBACHER St., Plymouth
ADDRESS
Dec. 30
53
Received and filed.
JAN 13 1954
19
(Registrar of City or Town where deceased resided)
PARENTS
6 Was disease or injury in any way related to occupation of deceased?
No
12/27/ 153
Vida-&&s) H111
Plymouth
19
Housewife
5 Accident, suicide, or homicfa
michal Spec 23/53
7:05 p.m.
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Auto aacids
place)
Injury
Multiple frastures, etc,
Ky.
20 MAIDEN NAME
OF MOTHER
Germany
Cliff St., Plymouth
R-305 1
M.S.
JAN10
TH
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY
294
53273 119
1. PLACE OF DEATH: STATE OF NEW YORK & COURTY
Steuben
L. TOWN
Bath
& CITY OR VILLAGE
4 yr .? mo 4 days
d. CITY OR VILLAGE Winthrop
·Is residence within Its corporate fim its? YES NO
d. RAME OF (If not In hospital or institution, give street address er location) HOSPITAL OR INSTITUTION Veterans Administration
& NAME OF DECEASED (Type of Print)
DONALD D. DELANY
4. DATE
OF
DEATH
(Month)
(Das)
(Year)
August 5
1953
6. SEX male
6. COLOR OR RACE white
17. SINGLE, MARRIED, WIDOWED, DIVALCER (+2%(y)
& IF MARRIED, WIDOWED OR DIVORCED, Rams of Husband (or) Wife Elizabeth Gallagher
1. DATE OF BIRTH 10/27/92
1& AGE Years 60
Months 9
Days 8
IF UNDER 24 HRS. Meurs
11. DIRTHPLACE (State or foreign country) Moline, Ill.
12. CITIZEN OF WRAT COUNTRYT ISA
13h. KIRD OF DUSIRESS OR INOUSTRY unknown
16. MOTRER'S MAIDEN NAME Elberta Cornwall
16. WAS DECEASED EVER IN U. S. ARMED FORCES? (Tel, no, or soknown) | (If yes, the yer, or dates of service).
17. SOCIAL SECURITY RO. 10-12-0/ 86
18. INFORMART'S RAME
VA Hospital Records, Bath. N Y
ADDRESS
19.
CAUSE OF DEATH
INTERVAL BETWEEN ONSET AND DEATH sudden
(A)_ DUE TO
Arteriosclerotic heart disease
8 yearo
(B) DUE TO
(C).
$20.0
2 yearo
20L. DATE OF OPERATION
20L. MAJOR FINDINGS OF OPERATION
21. AUTOPSY?
NO K
Ha. ACCIDENT. SUICIDE, HOMICIDE (Specify)
22h. PLACE OF IRJURY (e.g .. in or about beme, farts, factory, street, etce bldg., etc.)
22. WHERE DID
INJURY OCCURI
(City er lowa)
(County)
(State)
HIL TIME (Month) (Day) OF INJURY
(Year)
(Hour)
22e. INJURY OCCURRED Wolle at Work
Not While at Work
2. I hereby certify that Iattended the deceased from August 5, 19 53, 10
Xxxxxx and that death occurred at 6:50 am., from the causes and on the date stated above.
H.W.Baum, Acting Ch.Prof. Services
M. D.
24h. ADORESS
VAC, Path, NY
Ne. OATE SIGRED 8/5/53 19
3SL, PLACE OF BURIAL, CREMATION OR REMOVAL VA Center, Bath, N Y
25b. DATE
8/7/53 19
32 WATERER'S SIGNATURE
Reg . LICENSE RO.
27. DATE FILED BY LOCAL | 28 REGISTRAR'S SIGNATURE 8/5/53 REG. 000 allis
21b. URDERTAKER'S ADDRESS Bath, NY
Burial o { Permit igraya by JOS. A. CHIARONR
Date of issue. 8/5/53 19
Received and filed ..
19 .....
DATE FILED
19
(Registrar, of City or Town where deceased resided)
50m-(e)-10-48-24658
For VS No. 60
BE LEGIBLE. THIS IS A PERMANENT RECORD. TYPEWRITE, HAND-PRINT, OR WRITE LEGIBLY IN PERMANENT BLACK OR BLUE-BLACK INK. PENCILS, COLORED INKS, OR BALLPOINT PENS SHOULD NEVER BE USED. SIGNATURES SHOULD THIS CERTIFICATE MUST BE FILED WITH THE LOCAL REGISTRAR WITHIN 72 HOURS AFTER DEATH MARGIN RESERVED FOR BINDING
Diet. No ...... 5098 To be inserted by registrar
New York State Department of Health OFFICE OF VITAL STATISTICS CERTIFICATE OF DEATH
Registered . No.
2. USUAL RESIDENCE (Where deceased Ifred. If Jostitutlou: residence before & STATE Mass. b. COUNTY Suffolk admission).
. LENGTH OF STAY IR TOWN. CITY OR VILLAGE
C. TOWN
e. STREET ADDRESS 241 Washington Avenue
110. USUAL OCCUPATIOR (Otre kind of work done during meet of working life, eren !! Advertising Executive retired)
1. FATHER'S NAME
John Delany
1 DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
(This does not mean the mode of dying, e.g., beurt fatture, antenie, ete. It means the disease, injury or complication which caused death.) ANTECEDENT CAUSES DISEASES OR COROITIONS, If any, Firing rise to the above cause (A) stating the UNDERLYING CONDITION Last.
Acute coronary thrombosis
MEDICAL CERTIFICATION
OTRER SIGNIFICANT CONDITIONS contribut- ing to the death, but not related to the dincare or condition causing it.
Diabetes mellitus
(See Reverse for Instructions)
A R-302
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.)
2H. ROW OID INJURY OCCUR?
T
م
6
١
1
-
..
...
..
一年中市中興
--- 444
ப்பு வரும் .
الموجة الحالية.
......
இளசவு ஆகும்
مهم
.... +44.
40
...
...
. .
-------
---- வ ச்சபடம்டிர க்கு ஏழு -* சல்
சக்ஷ்டிஆன்இஸ்வர் அனு 1.ஓவியம்
4
பாசில் - ஆற்றிற்பம் கிரியேட்டி வீடு-அர ப்பாதை பிர சன்
中专学年
---
நாம் -த்ரினி-
4号牛肉
-
...
..
நேர்டிஸ்னி
ஹோம் -- ---- ன்ஸ் இல்சீஸ்பரி சி கள் - ல் ஆபத்து
ஆர்ஸ்வீட் ம்-
------
..
வியாபாரி அதி
---- பாடிஆ ஆட்டு ஸ்ட்சாப்ட்ஆம் ஸ்ட
சி வேந்தஸ்கு ஈட்ட
வழக்குரைவிட -ஸம்
அப்போதுவர்றுச திரிபுகுந்த
شيبسبع بيجاسوسنوفوسيس
- ---
என்பது ஆன் மங்கி!
..
---
- -- - டிஸ் விற்பனை செய்ற்றம் - கி முனி
معه
LA
..
சூரியன் எரிவதுவனை இழந்தமதிக்கு
--------
خاصية لموضد حم - - إد واية صربسلة جمجمبانة كافيه
1 4444
....
トー
4 ....
4北市
ஆடிரன்ஸ் எஸ்
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