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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