Town of Winthrop : Record of Deaths 1954, Part 5

Author: Winthrop (Mass.)
Publication date: 1954
Publisher:
Number of Pages: 566


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1954 > Part 5


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OSTON


(City or town making return)


Registered No.


559


13


f(If death occurred in a hospital or institution, No.


St. [ give its NAME instead of street and number)


2 FULL NAME


RUSSELL ? FLOYD


(a) Residence.


No.


25 Marshall


(Usual place of abode)


8


MEDICAL CERTIFICATE OF DEATH


(Month)


(Day)


4 I HEREBY CERTIFY,


4/22


53


19


to


ANTE


Due To


Carcinoma .... of


CEDENT (b)


the


cinomatosis


Due To


(c)


OTHER


SIGNIFICANT


CONDITIONS


Major findings:


Of operations


Date of operation


What test confirmed diagnosis ?.


autopsy


(Address) ..... VAH.


Place of Burial or Cremation


25M-3-53-909098


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,


CAUSES


prostate with car-


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


January


1.7


1954


(Year)


8 SEX


M


9 COLOR OR RACE


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


Married


10a If married, widowed, or divorced


HUSBAND of.


Holen Tewksbury


(Give maiden name of wife in full)


I last saw h .......


alive on.


-19 ..


.. , death is said to


m.


INTERVAL BE-


11 IF STILLBORN. enter that fact here.


9


.60


12


AGE


Years.


Months.


Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Expressman


(Kind of work done during most of working life)


14 Industry


or Business:


Tewksbury Express Co.


15 Social Security No ...


16 BIRTHPLACE (City)


(State or country)


Mass


winthrop


17 NAME OF


FATHER


William Floyd


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Mass


19 MAIDEN NAME


OF MOTHERHarriet Tucker


20 BIRTHPLACE OF


MOTHER (City)


Winthrop


6


Winthrop .... Com


Winthrop. ..... Mass.


(State or country)


Mass


City of Town)


DATE OF BURIAL.


19


Jan 20


54


7 NAME OF


FUNERAL DIRECTOR


H .... Reynolds


ADDRESS.


Winthrop Mass


Received and filed.


19


(Registrar of City or Town where deceased resided)


PARENTS


21


Informant


VAHospital .... Records


(Address)


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


DATE FILED


Jan 21


.....


..........


1954


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(Was deceased a


U. S. War Veteran,


NW I


if so specify WAR).


Winthrop, Mass.


St.


60


(If nonresident, give city or town and State)


Length of stay: In place of death ............ years ..


.. months


26


That


VIAattended


deceased_from


1/17


54


19


have occurred on the date stated above, at] ... 4.5p


DISEASE OR CONDITION


TWEEN ONSET


AND DEATH


DIRECTLY LEADING


TO DEATH (a) ..


Chronic .... glomerulo-


nephritis with uremlia-Wks


Mos


Was autopsy performed ?.


yes.


intirop.


5 Was disease or injury in any way related to occupation of deceased? .no


If so, specify


(Signed) ......


R Dwight


M. D.


Date.


7/17


.19 .... 5.4


MS.


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.)


M R-302 1


CERTIFICATE OF DEATH


VeteransAdministration Hospital


days.


In place of residence


.... years ..


months.


... days.


(or) WIFE of.


(Husband's name in full)


DATE OF ENTERING MILITARY SERVICE - 7/27/17


= = DISCHARGE


3/24/20 RANK, RATING


Cpl


ORGANIZATION & OUTFIT


U S Army


SERVICE NUMBER


52249


4


FEB-1


M R-302


X PLACE OF DEATH


L SUFFOLK BOSountyN


(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.


527 14


J(If death occurred in a hospital or institution, No. Peter.BentBrigham Hospital


XSCx give its NAME instead of street and number)


2 FULL NAME WILLIAM FUSSELL JR.


(If deceased is a married, widowed or divorced woman, give also maiden name.)


220 Woodside Ave ..


Winthrop ....... Mass.


(If nonresident, give city or town and State)


Length of stay: In place of death ..


... years ..


.months


days. In place of residence.


8


.. years.


.. months.


.. days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


January


17


1954


(Month)


(Day)


(Year)


THEREBY CERTIFY,


That T


attended deceased from


1/16


19


to


1/17


1954


WO I last saw him


alive on.


1/17


54


death is said to


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


have occurred on the date stated above, at6 .:. 50p. m.


DISEASE OR CONDITION


DIRECTLY LEADING


TO DEATH (a)


Uremia


Oliguria


TWEEN ONSET AND DEATH 2wks 4days


11 IF STILLBORN, enter that fact here.


12


AGEL.4 ..... Years.5.


.. MontR2.9.


Days


If under 24 hours


.Hours .....


Minutes


Due ToC


(b)


Congestiveheart


failure


2days


13 Usual


Occupation :..


·Student


(Kind of work done during most of working life)


14 Industry


or Business:


Junior High School


15 Social Security No.


16 BIRTHPLACE (City).


(State or country)


Somerville , Mas's.


OTHER


SIGNIFICANT


CONDITIONS


Major findings:


Of operations.


.Was autopsy performed ?.


.....


.no


What test confirmed diagnosis?


clinical


5 Was disease or injury in any way related to occupation of deceased?


If so, specify


V Cass


M. D.


(Signed).


(Address) ...... P.B.BH


Date.


1/18 .164


Winthrop


6 Winthrop


Place of Burial or Cremation (City or Town)


DATE OF BURIAL


Jan 19


54


7 NAME OF


FUNERAL DIRECTOR.


R .... Kirby


ADDRESS


EBoston


Received and filed.


19


(Registrar of City or Town where deceased resided)


PARENTS


17 NAME OF


FATHE


William R Fussell, Sr.


18 BIRTHPLACE OF


FATHER (City)


.Nowark.


(State or country)


N.J.


19 MAIDEN NAME


OF MOTHER


Vera E Colucci


20 BIRTHPLACE OF


MOTHER (City)


East .... Boston


(State or country)


Mass


21


Informant.


(Address)


Father


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred) Jan 20 54


DATE FILED


19


X


25M-3-53-909098 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 ANTE CEDENT CAUSES


(c) Due ToChronic glomerulo- nephritis


3yrs.


8 SEX


M


9 COLOR OR RACE


(write the word)


10 SINGLE


MARRIED


WIDOWED


or DIVORCED ingle


INTERVAL BE-


(Was deceased a


U. S. War Veteran,


if so specify WAR)


(a) Residence. No. (Usual place of abode)


Date of operation.


FEB-1


R-301A 1


PLACE OF DEATH


Boston 8/5/54


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD


CERTIFICATE OF DEATH


Registered No.


15


[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number) No. Jacob


2 FULL NAME.


(If deceased is a married, widowed or divorced woman, give also maiden name.) 168 alletin St. Brugliten


(a) Residence. (Usual place of abode)


Length of stay: In place of death. .years. months 2% days.


In place of residence. B ... years.


months .. .days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


January (Month)


17 11954 (Year)


8 SEX


Male


9 COLOR OR RACE


White


10 SINGLE MARRIED WIDOWED or DIVORCED


(write the word)


Married


4 I HEREBY CERTIFY,


July 10 1953


January 17 1954


last saw h un alive on Koumay 17 ios / death is said to


have occurred on the date stated above, at 1:30H


.. m.


INTERVAL BE-


(Husband's name in full)


TWEEN ONSET AND DEATH 11 IF STILLBORN, enter that fact here.


3 days 212 AGE.7.7. Years


Months. Days


If under 24 hours


Hours


Minutes


ANTE CEDENT (b) QUEScams - Stokes Syndrome)


2 week


13 Usual


Occupation :


Retired


(Kind of work done during most of working life)


14 Industry


or Business:


Realestate


Spasimo Fractured left jiw 6 were


OTHER SIGNIFICANactual Mit Cheput CONDITIONS 8,9,10


3 days


17 NAME OF


FATHER


Wolf Saperstein


Major findings:


Of operations


Date of operation.


What test confirmed diagnos chemical & lab


Was autopsy performed ?.


5 Was disease or injury in any way related to occupation of deceased? Wo


If so, s


(Signed)


(Addsè


M. P.


-


6 Ohel Jacob Place of Burial or Cremation


DATE OF BURIAL


(City or Town) January 18 1954


7 NAME OF


FUNERAL DIRECTOR.


Henry .... Levine


ADDRESS470 Harvard St., Brookline


Received and filed. 19


(Registrar)


PARENTS


18 BIRTHPLACE OF FATHER (City) (State or country)


Russia


19 MAIDEN NAME OF MOTHER Rachael (unknown)


20 BIRTHPLACE OF MOTHER (City) (State or country)


Mrs. Minnie Saperstein


168 Allston St., Brighton


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:


WI.G. Baker.


(Signatyff Agent of Board of Health or other)


H.o.


(Official Designation)


Jan. 18-195 x (Date of Issue of Permit)


X


I


3 - 4 200


15 Social Security No.


16 BIRTHPLACE (City) (State or country)


Russia


2 Skulle St. Wantugo 1/02/


woburn


50M-5-52-907046


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


d conditions, ing rise to the e (a) stating lying cause


ions contrib- death but not he disease or ausing death.


Heart Block


Due Corcho- vascular (c)


10a If married, widowed, or divorced HUSBAND of


Minnie Snyder


(Give maiden name of wife in full)


(or) WIFE of


DISEASE OR CONDITION


DIRECTLY LEADING


Coralie Hamonhage


(Day)


That I attended deceased from


X Suffolk (County) Winthrop 52. (City or Town) Winthrop Community Hospital Saperateur


To be filed for burial permit with Board of Health or its Agent.


PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran, if so specify WAR) No


(If nonresident, give city or town and State)


Russia


21 Informant. (Address)


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 eath of a person whom he has attended during his last illness, at the request f an undertaker or other authorized person or of any member of the family of he deceased, furnish for registration a standard certificate of death, stating to the est of his knowledge and belief the name of the deceased, his supposed age, the isease of which he died. defined as required by section one, where same was ontracted, the duration of his last illness, when last seen alive by the physician r 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 receding section or by section forty-five of chapter one hundred and four- een, shall, if the deceased, to the best of his knowledge and belief, served in the rmy, navy or marine corps of the United States in any war in which it has been ngaged. insert in the certificate a recital to that effect, specifying the war, and hall also certify in such certificate both the primary and the secondary or imme- iate cause of death as nearly as he can state the same. For neglect to comply ith any provision of this section, such physician or officer, shall forfeit ten dollars." or the purposes of this section and of sections forty-five, forty-six and forty-seven- f said chapter one hundred and fourteen, the word "war" shall include the China elief expedition and the Philippine insurrection, which shall, for said purposes, be eemed to have taken place between February fourteenth, eighteen hundred and inety-eight and July fourth, nineteen hundred and two, and the Mexican border ervice of nineteen hundred and sixteen and ninetcen hundred and seventeen./ . L. Chap. 46, Sec. 10.


No undertaker or other person shall bury or otherwise dispose of a human body a town, or remove therefrom a human body which has not been buried, until he as received a permit from the board of health, or its agent appointed to issue ich permits, or if there is no such board, from the clerk of the town where the erson died; and no undertaker or other person shall exhume a human body and move it from a town, from one cemetery to another, or from one grave or tomb ther than the receiving tomb to another in the same cemetery, until he has ceived a permit from the board of health or its agent aforesaid or from the clerk [ the town where the body is buried. No such permit shall be issued until there all have been delivered to such board, agent or clerk, as the case may be, satisfactory written statement containing the facts required by law to be turned and recorded, which shall be accompanied, in case of an original inter- ent, by a satisfactory certificate of the attending physician, if any, as required by w, or in lieu thereof a certificate as hereinafter provided, If there is no attending hysician, or if, for sufficient reasons, his certificate cannot be obtained early nough for the purpose, or is insufficient, a physician who is a member of the board f health, or employed by it or by the selectmen for the purpose, shall upon pplication make the certificate required of the attending physician. If death is aused by violence, the medical examiner shall make such certificate. If such a ermit for the removal of a human body, not previously interred, from one town another within the commonwealth cannot be obtained early enough for the urpose, the certificate of death made as above provided and in the possession of he undertaker desiring to make such removal shall constitute a permit for such moval; provided, that such hody shall he returned to the town from which it was emoved within thirty-six hours after such removal, unless a permit in the usual orm for the renioval 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 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 he held, or from a person appointed to have the eare 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:


to,


(1X) Attending physicians will certify to such deaths only as those of persons 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


1


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


X


PLACE OF DEATH


Suffolk (County)


Bos ton


(City or Town)


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


Bosta


(City or town making return)


Registered No. ...


16


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.)


(a) Residence. No.


3.06.Sag


(Usual place of abode)


Length of stay: In place of death


.years .......... month


29


.days. In place of residence .... 3 .. years


months.


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR OR RACE


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


Widowed


4 I HEREBY CERTIFY.


That I


attended deceased from


19.53


to


Jan. 19 19 .. 54


I last saw h


.alive on


19


..... , death is said to


have occurred on the date stated above, at.


INTERVAL BE-


(Husband's name in full)


DISEASE OR CONDITION


DIRECTLY LEADING


TO DEATH (a)


Paleomany ... congo


tim


TWEEN ONSET AND DEATH


11 IF STILLBORN, enter that fact here.


12


AGE.


78 Years


8


Months


15


.Days


If under 24 hours


Hours.


Minutes


ANTE


Due To


Dronchorenic carcinaha


CEDENT (b)


right upper tobe with


howsnow to liver,


Due To


(c)


adrenal md allmimi


lymph nodes and spinp


OTHER SIGNIFICANT CONDITIONS


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)


LJ Marks


M. D.


(Address)


Date.


19 ..


Place of Burial or Cremation (City of Town)


DATE OF BURIAL. Jan 23/51. 19


7 NAME OF


FUNERAL DIRECTOR


M W Kirby


ADDRESS


Winthrop Mass.


Received and filed.


FEB


19


(Registrar of City or Town where deceased resided)


PARENTS


17 NAME OF FATHER


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Ireland


19 MAIDEN NAME


OF MOTHER


tory Mitchell


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Ireland


21


V A Hospt "records


Informant


(Address)


E COPY Le


A. mach


Boston 30 Mass"


DATE FILED


ATTEST:


(Registrar of City of Town where death occurred)


Jan. 25/54


19


1


25M-10-53-910621


6 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, CAUSES


M R-302 1


No. V.et.c


.... Adm.Hospt, Booten Moss.


John F. Winston 5


St.


(Was deceased a


U. S. War Veteran,


if so specify WAR)


(write the word)


3 DATE OF


DEATH


(Month)


20/51


(Day)


(Year)


Days


13 Usual


Occupation:


General Organizer


(Kind of work done during most of working life)


14 Industry


or Business:


15 Social Security No.


16 BIRTHPLACE (City).


(State or country)


Gast Boston W103.


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


(If nonresident, give city or town and State)


FED-0


Entered Service 6-29-18 Discharged 4-23-19 Capt. CMC US Army


X


PLACE OF DEATH


SUFFOLK BUS ( County )


(City or Town)


The Children


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


(City or town making return)


Registered No.


589


17


f(If death occurred in a hospital or institution, .xSt. give its NAME instead of street and number)


2 FULL NAME.


MARILYN BARNARD


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No.


(Usual place of abode)


321 Pleasant


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.


Hospital-19hrs-45mins


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


F


9 COLOR OR RACE


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


(Month)


(Day)


(Year)


That


I


attended deceased , from


4 I HEREBY CERTIFY,


1/19


19


1/20


19


54


I last saw h ..... Q.X.alive on


..


1/20


19.


death is said to


have occurred on the date stated above, at.


5:15am.


INTERVAL BE-


TWEEN ONSET


DISEASE OR CONDITION


DIRECTLY LEAPHEestinal obstruction


TO DEATH


(a).


AND DEATH


11 IF STILLBORN, enter that fact here.


12


AGE


7


Years


8


Months.


28


.Days


If under 24 hours


Hours .....


. Minutes


13 Usual


Occupation:


(Kind of work done during most of working life)


14 Industry


or Business:


Student


15 Social Security No.


Boston


16 BIRTHPLACE (City)


(State or country)


Mass


17 NAME OF


FATHER


Chester S Barnard


18 BIRTHPLACE OF


Boston


FATHER (City).


(State or country)


Mass


19 MAIDEN NAME


OF MOTHER


Dorothy Wel ling


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


East Boston


Hass


6


Winthrop


Winthrop


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


Jan 22


19


7 NAME OF


FUNERAL DIRECTOR


J O'Maley


ADDRESS.


Anthrop ,Mass


19


Received and filed


(Registrar of City or Town where deceased resided)


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


C strangulated small


ANTE


Due To


bowel


CEDENT (b)


CAUSES


Post operative ad-


Due To


he sions


OTHER


SIGNIFICANT


CONDITIONS


Major findings:


Of operations.


Gangrenous segment ileum


Date of operation


1/20/54 Was autopsy performed?


What test confirmed diagnosis?


5 Was disease or injury in any way related to occupation of deceased ?...... no-


: If so, specify ....


(Signed).


S Schuster


M. D


(Address).


Children !...... Hos Date.


1/2010 54


PARENTS


Informant


C .... Barnard


(Address)


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


Jan 22


54


DATE FILED


.19


X


3 DATE OF DEATH 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 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, (c)


M R-302 1


No.


Hospital


(Was deceased a


U. S. War Veteran,


if so specify WAR)


"ingle


January


20


1954


54


FEB-1 14


PLACE OF DEATH


Aufalle (Countyy Nontrop


The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


To be filed for burial permit with Board of Health or its Agent.


Registered No.


18


(City or Town) 178 Highland ane. No.


J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME ..


(I deceased is a married, widowed or divorced woman, give also maiden name.) 178 Highland are.


St.


(If nonresident, give city or town and State)


Length of stay: In place of death years. months.


days. In place of residence.


24


.years


.months


... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


Can. (Month) (Day)


26


1954


(Year)


4 I HEREDY CERTIFY. Oct .


1952


Jan. 26


19 54


I last saw


im alive


Jan. 26, 1954, death is said to


have occurred on the date stated above, at.


1:00P.m.


INTERVAL BE- TWEEN ONSET ANO DEATH


DISEASE OR CONDITION


DIRECTLY LEADING


TO DEATH


(a) Carcinoma ofcolor


metastatic CarcinQua


ANTE Due To


CEDENT (b) CAUSES


Due To (c)


OTHER SIGNIFICANT CONDITIONS


Major findings: Of ofera ons ...


Cestinonay Colou C le


Date of operation.


1949 Was autopsy performed? 200 Pathological exam.


What test confirmed diagnosis ?.


5 Was disease or injury in any way related to occupation of deceased? Wo If so, special timeles (Signed). Liberman M. D. (Address) Wurderay, Note 1/26/1994.


6 Place of Burial or Cremation (City or Town)


DATE OF BURIAL .. Jan 29 19


7 NAME OF FUNERAL DIRECTOR




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