USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1954 > Part 54
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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 retumed as at(school of it 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.
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
...
SUFFOLK E (County) IN
(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.
6412161
2 FULL NAME.
JUS SOLIMBERG
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. (Usual place of abode)
25 .... Sturgis
.....
.........
St.
(If nonresident, give city of 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
(Month)
July
.23
1954
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended , deceased from
was
D
19 ..
5
I last saw h
alive on
19
death is said to
have occurred on the date stated above, at.
10:20p.
.m.
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) cerebral hemorrhage
6wks
ANTE
Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER SIGNIFICANT CONDITIONS
Major findings:
Of operations.
Date of operation
Was autopsy performed?
What test confirmed diagnosis?
clinical
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed).
H Migro
M. D.
(Address)
BOŘ
Date.
7/23 54
6 Place of Burial of Cremation th Target of Winthrop Everett
DATE OF BURIAL .................... 2.5 19 .. 5.4
7 NAME OF
FUNERAL DIRECTOR ..... Torf.
ADDRESS
Chelsea, Mass
Received and filed. 19
A TRUE COPY
Parkes H. Mackie
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Jul 27
54
......
.19
(Registrar of City or Town where deceased resided)
11 IF STILLBORN, enter that fact here.
12
AGA5
.. Years.
Months.
Days
If under 24 hours
Hours .....
Minutes
13 Usual
Occupation:
Dealer
(Kind of work done during most of working life)
14 Industry
or Business:
Waste Materials
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Chelsea, Mass
17 NAME OF
FATHER
Isaac Steinberg
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country)
19 MAIDEN NAME
OF MOTHER
Russia
20 BIRTHPLACE
dida Payman
MOTHER (City)
(State or country)
Russia
21
Informant
(Address)
B Steinberg
25M-3-53-909098
No.
Boston City Hospital
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
XXX
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(write the word)
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
7/23
19 ..
to
...
10a If married, widowed, or divorced
HUSBAND of.
Bobby .....
Give maiden name of wife " fuii)
(or) WIFE of
(Husband's name in full)
INTERVAL BE-
TWEEN ONSET
AND DEATH
8 SEX
9 COLOR OR RACE
M R-302 1
WIIn UNPAVING BLACK INK - THIS IS A PERMANENT RECORD
AUG-2
X
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
162
No. Winthrop community Hospital ercy FRANK P. Churchill
(If deceased is a married, widowed or divorced woman, give also maiden name.)
369 Winthrop St.
WINtheop, MASS.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death. years .. . .months. 4 days. In place of residence 1 .years . 3
.months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
7
(Month)
24 (Day)
54 (Year)
8 SEX
Male
white
10 SINGLE
write the word)
MARRIED Widowed
WIDOWED
or DIVORCED
4 I HEREBY CERTIFY,
That I attended deceased from
July 21 -
5%
July at
19
54
I last saw h. Im alive on
July 24
19 9, death is said to
have occurred on the date stated above, at
7
p.m.
INTERVAL BE- TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE 87
.Years
6 . Months
Days
If under 24 hours
Hours .. Minutes
13 Usual
Occupation:
retired salesman
(Kind of work done during most of working life)
14 Industry
or Business:
Safe and vault Mfg.co.
15 Social Security No. UNABLE TO OBTAIN
16 BIRTHPLACE (City)
(State or country)
Freedom
N.H
17 NAME OF
FATHER
John C. Churchill
18 BIRTHPLACE OF
FATHER (City)
North Parsonsfield
(State or country)
Maino
5 Was disease or injury in any way related to occupation of deceased ?.
NO
-
. M. D.
cremation Woodlawn cem. Everett, Mass Place of Buriaf or Cremation
DATE OF BURIAL. July 27 195411/ E ... 19
7 NAME OF
FUNERAL DIRECTOR
Afull Mariah
ADDRESS
174 Winthrop St, Winthrop,
Received and filed SUL 2/ 1954 19
(Registrar)
PARENTS
19 MAIDEN NAME
OF MOTHER
Annie Burk
20 BIRTHPLACE OF MOTHER (City) (State or country) Penna.
21 Informant (Address) Preston B. churchill
369 Winthrop St.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or trapsit permit was Issued:
Mass Walter& Hakers (Signature ofrAgent of Board of Health or othery Healthe Office 7 21 54
(Official Designation) (Date of Issue of Permit)/
RUCTIONS 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 th.
d conditions, ing rise to the e (a) stating lying cause
tions contrib- death but not he disease or ausing death.
SOM (B)-1-51 903586
OTHER
SIGNIFICANT
CONDITIONS
Arteriosclerotic HEART
Disease with congestive.
HEART FAILURE.
Major findings:
Of operations
NONE
Date of operation.
.Was autopsy performed?
NO
What test confirmed diagnosis?
CLINICAL
If so, specify, (Signed) (Address) Winthrop, MASS Date 7.24 195+
10a If married, widowed, or divorced
HUSBAND of.
Florence Daniels
Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) PRIMARY APLASTIC ANEMIA
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
I R-301A 1
Registered No.
J(If death occurred in a hospital or institution,
St. [ give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No.
(Usual place of abode)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
NO.
9 COLOR OR RACE
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted. the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall. if the deceased, to the best of his knowledge and belief. served in the army, navy or marine corps of the United States in any war in which it has been engaged. insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five. forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and. ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of ninetcen hundred and sixteen and nineteen hundred and seventeen .. G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried; watil he, has received a permit from the board of health, or its agent appointed tof 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
0
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 inake examination upon the view of the dead bodies of persons as are supposed to have died by violence. or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. - General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4. Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made.
Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow- ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness front 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 RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
M 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 after the close of the month in which the death occurred. (See Chap. 46, Sec 12, G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible,
25M·3-53-909098
PLACE OF DEATH
SUFFOLK
BO'SCounty). 2 . 0 8
(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.
6407163
(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number) XX
2 FULL NAME. ABRAHAM MARDEN
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. (Usual place of abode)
24 Coral Ave
.......
.»St.
-
(If nonresident. ive tity wn and State)
Length of stay: In place of death ... ].Q. years. ..... months days. In place of residence .. 35 .. years .. .months. .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
24(Day)
1954/ear)
8 SEX
M
9 COLOR OR RACE
10 SINGLE
(write the word)
MARRIED WIDOWED or DIVORCEDWidowed
4 I HEREBY CERTIFY,
That I
attended deceased from
10a If married, widowed, or divorced
11/21 1948 to
7/24.
19
5 4HUSBAND of
Fannie
maiden hame of wife in full)
I last saw h ....... f.malive on 7/24 19 .. 5 4 death is said to
(or) WIFE of.
(Husband's name in full)
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) ...... cerebral hemorrhage
TWEEN ONSET AND DEATH 11 IF STILLBORN, enter that fact here.
7/19/544
AGE92
Years
Months.
.Days
If under 24 hours
Hours
Minutes
ANTE
Due To
CEDENT (b)
CAUSES
bronchopneumonia"
Due To (c) hypertensive ... heart. disease
11/21
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)
B .... Udolson
M. D.
(Address). 460 Geneva Ave
.19 ...
6 Place of BunDaCid Pation (City of Turn
DATE OF BURIAL J.,1.25 19.54
7 NAME OF
FUNERAL DIRECTOR
B ... Birnbach
ADDRESS
Dorchester
Received and filed
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF FATHER (City). (State or country)
Bussi &
19 MAIDEN NAME
OF MOTHER
Deborah - --
20 BIRTHPLACE OF MOTHER (City) (State or country) Russia
21 Informant. Hebrew ... H. me ..... for .... Agod.
(Address _
TRUE COPY orles " Mackie
ATTEST:
19
(Registrar of City or Town where death occurred)
DATE FILED
Jul 27
19 ....
54
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No ...
6 BIRTHPLACE (City). (State or country) Russ a
17 NAME OF
FATHER
William Marden
7/23/54
13 Usual
Occupation :
Real Estate - ret
have occurred on the date stated above,
5:55a.
.... m.
INTERVAL BE-
Date
7/84 54
WALLE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
No. Hebrew Aged Home
(Was deceased a
U. S. War Veteran,
if so specify WAR)
AUG -FI 79
X
PLACE OF DEATH
Suffolk
(County)
Bos ton
(City or Town)
Mass. General Hospt No.
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)
6438
Registered No.
164
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME Vincent Marotta
(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.
28 .... Beach Road
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.
Ili ....... years.
months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Month)
July 24/54
Day
(Year)
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
4 I HEREBY CERTIFY,
That I
attended deceased from
July 18
54.
to
I last saw h.4 mm
alive on
July 2l' 19.1 death is said to
have occurred on the date stated above. at
.m.
1.25PM
INTERVAL BE- TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE
Years
2
Months
.Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation:
Shoe Maker
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
Coronary thrombosis 1 Week BIRTHPLACE (City). Italy
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation
Was autopsy performed ?. Yes
What test confirmed diagnosis?
suteDay
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
M. D.
(Address)
CL Clay
.. Date
19.
24-50
Mass. General Hospt
Place of Burial or Cremation throp Cem-Icintrom Mass DATE OF BURIAL
July 27/54
19
7 NAME OF
FUNERAL DIRECTOR
E P Caggiano
ADDRESS Winthrop Mass.
Received and filed 19
(Registrar of City or Town where deceased resided)
PARENTS
17 NAME OF
FATHER
Louis Marotta
18 BIRTHPLACE OF
FATHER (City).
Italy
(State or country)
19 MAIDEN NAME
OF MOTHER
Unknown
20 BIRTHPLACE OF
MOTHER (City)
Italy
(State or country)
21
Informant
(Address)
Louis Marotta
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
July 28/54
.19
DATE FILED
X
............. , WIIn UNFADING BLACK INA - THIS IS A PERMANENT RECORD
6 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, CAUSES
ANTE
CEDENT (b)
Due To
Myocardial ... infarcti m
One
Due To (c)
Week
10a If married, widowed, or divorceanna Tasca
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Rupture of heart"
Mins. 84
(State or country)
M R-302 1
1.5.
(Usual place of abode)
19 ...
AUG-2
PLACE OF DEATH
Suffolk
County) Winthrop (City or Town) 435 Shirley St
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
165
(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME.
Elizabeth J. Netener
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
435 Shirley St.
(Usual place of abode)
Winthrop Man
(If nonresident, give city or town and State)
Length of stay: In place of death ........
.years.
.. months.
days. In place of residence ..
13
.. years
months.
.days.
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
24
1954
(Year)
9 SEX
Female
10 COLOR OR RACE
White
11 SINGLE
MARRIED
WIDOWED Urried
or DIVORCED
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.)
ACUTE
CARDIAC
DILATATION
11a If married, widowed, or divorced
Lowell Of Neterer
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
AGE 50
Years
4
Months
3
Days
If under 24 hours
Hours
Minutes
14 Usual
Occupation :.
Housewife
(Kind of work done during most of working life)
15 Industry
or Business:
Own Home
16 Social Security No.
011-03-8568
East Boston
17 BIRTHPLACE (City)
(State or country)
Massachusetts
18 NAME OF
FATHER
Arsenius J. Kelly
19 BIRTHPLACE OF
FATHER (City).
East Boston
(State or country)
Massachusetts
20 MAIDEN NAME
OF MOTHER
Helen C. Healy
21 BIRTHPLACE OF
New Castle
MOTHER (City)
(State or country)
New Brunswick
22 Helen A. Millerick
Informant
(Address)
115 Summit Ave Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the buriabor transit permit was issued: Walter I taller
(Signature of Agent of Board of Health or other)
Health Officer
7/17:54
(Official Designation) (Date of Issue of Permity
(Registrar)
PARENTS
M. D.
(Address 25 hattuck St Date 7/2/1950
Holy Cross Cemetery Malden
DATE OF BURIAL.
July 28
1954
ADDRESS. 11 Meridian St. East Boston
Received and filed JUL .2.7.1954
1 R-303 A y Book .. TIER ST No.
Every item of MEDICAL CERTIFICATE OF DEATH (Month) (Day) 5 Accident, suicide, or homicide (specify) Date and hour of injury 19 Where did Injury occur ?. (City or town and State) place? (Specify type of place) Manner of Injury (How did injury occur?) Nature of Injury 6 Was disease or injury in any way-related toloccupation of deceased ?. If so, specy. (Signedy 7 Place of Burial, or Cremation. (City or Town) 8 NAME OF FUNERAL DIRECTOR Alice M. Kelly If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. of Death. See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should stato CAUSE AND MANNER OF 25M-1-52-906135 N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK -THIS IS A PERMANENT RECORD. While at work? Was autopsy performed?yes
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
No
if so specify WAR).
(write the word)
Did injury occur in or about home, on farm, in industrial place, or in public
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.
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