USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1955 > Part 25
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Medical examiners all 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, therbial or electricaliagents 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, CHạp. 38. Sec. 6., as amended by Chap. 632, Sec. 4. Acts of 1945.
No undertakes, or other persons shall bury a human body or the ashes thereof which have been Hmm Mmto the commonwealth until he has received a permit so to do froutthe board of health or its agent appointed to issue such permits, or if there is no such wy dofrom the clerk of the town where the body is to be buried of the funeral is to be held, or from a person appointed to have the care of the cemetery or biofil ground in which the interment is made.
Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
APR-1 RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow- ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(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 .
RM R-301A 1
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.
Registered No. ...
68
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME .. Adeline S. Wood
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 22 North Ave
St.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death. ...... .. years months. days. In place of residence years months .days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
March
30
(Month)
(Day)
1955 (Year)
8 SEX
Female
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEbidowed
4 I HEREBY CERTIFY.
That I attended deceased from
1 March 19 55 to .... 30 March
19. 55
I last saw h .. & ....
... alive on
29 March 1955 death is said to
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Alexander Wood
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
79 Years
.Months.
Days
If under 24 hours
Hours ....
.Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City). (State or country) P. S. T.
17 NAME OF
FATHER
John E. McCallum
18 BIRTHPLACE OF FATHER (City) (State or country)
Cannot be learned
19 MAIDEN NAME
OF MOTHER
Margaret Dalton
20 BIRTHPLACE OF MOTHER (City) (State or country)
Cannot be learned
21 Informant Myrtle Kelly
(Address)
22 North Ave .. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Watter & Making
(Signature of Agent of Board of Health or other)
3/3/150
(Official Designation)
(Date of Issue of Permit)
100M-10-53-910621
7 NAME OF FUNERAL DIRECTOR ...
Tintin . O'malley
ADDRESS Winthrop Mass
Received and filed MAR 31/4955
.19
(Registrar)
PARENTS
5 Was disease or injury in any way related to occupation of deceased? no If so .: Arthur@Murray
(Address)
(Signed)
Winthrop
Date 30 march 1955
6 Winthrop
Winthrop (City or Town)
Place of Burial or Cremation
DATE OF BURIAL April 1
1,55
Major findings:
Of operations
none
Date of operation
Was autopsy performed? no
What test confirmed diagnosis?
clinical
30 yrs
CEDENT (b) ... CAUSES
Due To generalized
(c)
arteriosclerosis
30 yrs
OTHER SIGNIFICANT CONDITIONS
-
ANTE Due To hypertension
INTERVAL BE- TWEEN ONSET AND DEATH 3 yrs
have occurred on the date stated above, at 12:30 A.
DISEASE OR CONDITION DIRECTLY LEADING
TO DEATH
(a) cerebral hemorrhage
9 COLOR OR RACE
(Was deceased a U. S. War Veteran, if so specify WAR)
STRUCTIONS FOR AL CERTIFICATE
In giving E OF DEATH not enter re than one se for each ), (b) and (c)
is does not mean de of dying. such failure, asthenia, means the disease. plications which death.
orbid conditions. giving rise to the ause (a) stating derlying cause
nditions contrib- the death but not to the disease or n causing death.
15.
No.
22 North Ave. ,
54
Tignish
M. D.
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 nineteen 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, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by, section ten of chapter forty-six. that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate. shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114. Sec. 45, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies of persons as are supposed to have died by violence, or by the action of chemical chemal/ 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 La Sce -6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaket 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 theboard 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 fulllime! E the purpose of these laws calls for the observance of the follow- ing rule's of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deathsonly as those of persousato Though disabled by recognized disease unrelated to any form of injury, Have ched 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 poisuns) 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
RM R-305 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-305 to the clerk of the city or town in which the deceased resided as soon as possible
1
PLACE OF DEATH
SUFFOLK 1 BOSTON
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return)
1901 69
Boston City Hospital No.
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME
Frank Willett (or Willard)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
503 Pleasant St
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.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Male
10 COLOR OR RACE
White
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single
11a If married, widowed, or divorced HUSBAND of. (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
62
13
AGE
Years
Months.
.Days
If under 24 hours
Hours
.Minutes
14 Usual
Occupation :
Busboy
(Kind of work done during most of working life)
Restaurant
15 Industry
or Business :.
005-18-2915
16 Social Security No.
Fall River Muss
17 BIRTHPLACE (City).
(State or country)
18 NAME OF FATHER
19 BIRTHPLACE OF
FATHER (City).
(State or country)
20 MAIDEN NAME
OF MOTHER
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
-
George Cirlampa
22 Informant (Address)
A TRUE CORY.
Ethanle 21 Mackie
gistras of City or Town where death occurred)
DATE FILED
Mar 1
19 55
X
3 DATE OF
DEATH
Feb 9, 1955
(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.) Spontaneous cerebral hemorrhage
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?
(Specify type of 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)
R Ford
(Address)
Date ....
19
7
St Michael's Com
Bos ton
Place of Burial, or Cremation.
Feb 29
or Town 55 19
DATE OF BURIAL
J A Langone Jr
ADDRESS.
Received and filed APR 14 1999 19
(Registrar of City of Town where deceased resided)
PARENTS
279 155
8 NAME OF FUNERAL DIRECTOR Bos ton Mass
25m-(c)-11-49-900.475
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
Registered No.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
(Usual place of abode)
RECEIVED
OF TOWN
11 12 1
013-0
MIN
3
5
6
APR14 AM
ORM R-305 1
OF DEATH
(County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S
(City or town making return)
70
TISTICAL
RANSFER
MARYLAND STATE DEPARTMENT OF HEALTH-BALTIMORE, 18 MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Reg. Dist.
243
No.
2. USUAL RESIDENCE (HOME) OF DECEASED:
1. PLACE OF DEATH:
COUNTY Passei Georges
MARYLAND
STATE Maso
COUNTY
CITY (If outside corporate limita/ write HURAL OR and give nearest-toyrn) mitchelalle TOWN
LENGTH OF STAY (in this place)
CITY (If outside corporate limits write RURAL and give nearest towa) OR 58x-3 TOWN Winthrop
(If mural, give location>
HOSPITAL OR INSTITUTION OR STREET ADDRESS
Warme motel
STREET ADDRESS 169- Man Street
8. NAME OF DECEASED : (Type or Print)
Fvd-
Valentine
Rand
4. DATE OP DEATH 2 .- 14-855
5. SEX: 6. COLOR OR RACE:
7. SINGLE, MARRIED, WIDOWED, DIVORCED (Specify): Hanna
6-2-1994
yrs.
12. CITIZEN OF WHAT
10a. USUAL OCCUPATION (Give kind of work Bone during most of work life, Yeni getiren) :
| 100. KIND OF BUSINESS OR INDUSTRY : Soboter merchant
11. BIRTHPLACE (State or foreign country); Nova Scotia CandA 1989)
14. MOTHER'S MAIDEN NAME:
13. FATHER'S NAME: Qualrea Valentine Rand.
Manyfirma Barnaby.
15. WAS DECEASED EVER IN U.S. ARMED FORCES 7| 16. SOCIAL SECURITY NO .: (Yes, no, or unk.) | KIf Yes, give war or dates of service)
17. INFORMANT & ADDRESS: Dassey Grace Rand
18. MEDICAL CERTIFICATION
L DISEASES OR CONDITIONS DIRECTLY LEADING TO DEATH:
442× Immediate cause (.) ........ Centa congestive heart fachini
DUE TO
Antecedent cause(s) Diseases or conditions, if any, giving rise to the above cause DUE TO stating underlying cause last
(e)
IL OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO THE DEATH BUT NOT RELATED TO THE DISEASE OR CONDITION CAUSING DEATH
19a. DATE OF OPERATION: | 19b. MAJOR FINDING OF OPERATION:
20. AUTOPSY?
21a. EXTERNAL CAUSE WAS PRIMARY O OF CONTRIBUTING CAUSE OF DEATH.
21b. PLACE (Home, farm, factory, OF street, office bidg., etc.,
21e. (City or town) (County)
(State)
21d. TIME (Month) (Day) (Year) OF INJURY M
(Hour)
21e. INJURY OCCURRED
211. HOW DID INJURY OCCUR?
While at Not while
work [ at work O
22. I hereby certify that I took charge of the remains described above, held an Autopsy O, Inspection Er, Inquiry , and find that death resulted from: Natural causes 42, Accident , Suicide , Homicide , Undetermined cause O. SIGNATURE
CHIEF MEDICAL EXAMINER DEPUTY MEDICAL EXAMINER
DATE SIGNED
M. D. ASSISTANT MEDICAL EXAM.
2-15-55
AS. BURIAL, CREMATION, THEREOF J NAME OF CEMETERY OR CREMATORY
LOCATION (City/town, or county) (Stata)
REMOVAL TOOLIN EL N, 195 St winthrop
DATE REC'D HY LOCAL
REGISTRAR'S SIGNATURE
UHERAL DIRECTOR Paschi som Hyattentlang
2-18-55 Mrs. Ligues W. Viuguay
ADDRESS
Received and filed
19
(Registrar of City or Town where deceased resided)
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
3-7-55-
19
stitution, number)
:ate)
S
ite the word)
1
hours
Minutes
"king life)
(b) ........
Enchovascular rinaldisiage -
9. AGE, last birthday : | D UNDER 1 YEAR | D UNESE 24 BIS.
8. DATE OF BIRTH:
Months Days Hout | Min.
male
(First)
(Middle)
(Last)
(Month)
(Day) (Year)
INTERVAL BUTWIKI ONET AND DRATE
INJURY
Fred Apr 20
1
X
Medical Examiner Declined Jurisdiction
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Bostan
(City or town making return)
Registered No.
2092 71
Peter Bent Brigiam Hospt No.
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.)
52 Cutler St
St.
Winthrop Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death ........
.. years.
months
U
In place of residence. .
...... .. years.
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
(Month)
Feb.28/55
(Day)
(Year)
8 SEX
M
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
4 I HEREBY CERTIFY.
Feb.28
19
55
to
Feb.28.
155
I last saw
alive on
Feb.28 19 ... 55death is said to
have occurred on the date stated above, at.
3:LOA
m.
INTERVAL BE- TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE 62 Years
Months.
Days
If under 24 hours
.Hours.
Minutes
13 Usual
Occupation:
Poultryman
(Kind of work done during most of working life)
14 Industry
or Business:
Poultry
15 Social Security No.
021-09-0718
16 BIRTHPLACE (City).
(State or country)
Russia
17 NAME OF FATHER
Aaron
Lefkowitz
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
March 1/55
19
21 Informant (Address)
Marcia Lefkowitz
A TRUE COPY. ...
ATTEST:
(Registrar of City or Town where death occurred)
March 3/55
DATE FILED
........
19
V.B.V
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
25M-10.53.910621
PLACE OF DEATH
Suf folk
(County)
Bos ton
ORM R-302 1
3 DATE OF DEATH (c) Major findings: Of operations. 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 OTHER SIGNIFICANT CONDITIONS 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
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Rupture of aortic
aneurysm into left
pleural cavity
ANTE
Due To
CEDENT (b)
Generalized arterio
sclerosis
3 Yrs
Due To
Old anterior septal
myocardial infarction
Date of operation.
Was autopsy performed ?.
Yes
What test confirmed diagnosis ?..
autopsy.
5 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
V .... M ... Cass
M. D.
Peter Bent Brigham Hospt
12 .. 28-55
(Address)
Both ... Israel ... Everett. Mass.
7 NAME OF
FUNERAL DIRECTOR
H J Torf
Chelsea Mass.
ADDRESS
Received and filed
APR 18
19
(Registrar of City or Town where deceased resided)
PARENTS
10a If married, widowed, or divorced
HUSBAND of
Marcia Ziegler
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
(write the word)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
(Usual place of abode)
(City or Town)
Israel Lefkowitz
That I attended deceased from
Term.
RECEIVED
TO:
Co. 1
3
5
6
APR10
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,
X
Suffolk
(County)
Boston
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Boston
(City or town making return)
2289-22
Registered No.
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
Nathan Shore
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.) 31 Sturgis St
.......
St.
Winthrop Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death ..........
.. years ..
months.
14 days. In place of residence.
6.years
.months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
March 5/55
8 SEX
9 COLOR OR RACE
W
10 SINGLE
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