USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1955 > Part 32
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25M-10-53-910621
3 DATE OF
DEATH
CAUSES
6
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)
Pulmonary atelectasis
ANTE
Due To
CEDENT (b)
L Day
Due To
Duodenal ulcer
10a If married, widowed, or divorced
HUSBAND of
Ethel .E. Mclaughlin
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Pulmonary embolus
(write the word)
(Month)
March 15/55
(Day)
(Year)
RM R-302 1
PARENTSA
V.VI
RECEIVED
TO!
0)
11 12
10.
N
9-
3
5
6
MAY 12 "
C S
sed by Medical Examiner
RM R-302 1
PLACE OF DEATH
SUFFOLK 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)
Registered No.
288, 90
No. Mass ... GeneralHospital
....
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME .. Eurene W Orcutt
(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.
(Usual place of abode)
24 Beacon St
St.
Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In place of death. years. months. IQlays. In place of residence. 50.years. .. months .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Mar 19, Da
1955
(Year)
(Month)
4I HEREBY CERTIFY,
That I attended deceased from
Mar 9 19 55. to .. .Mar .... 19 ...... 19.5.5. I last saw h ... 1.m .... alive on .......... M./s.r ..... 1.9 ........ 19 .. 55 death is said to
have occurred on the date stated above, at ..... ] ... 50 ..... p.m.
INTERVAL BE- TWEEN ONSET AND DEATH
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a).Carcinoma .... prosta to.
with generalized metastasis
ANTE
Due To
CEDENT (b) CAUSES
Due To (c)
OTHER
SIGNIFICANT Subdural .... hemorrhage .....
CONDITIONS
1 day
Major findings:
Of operations.
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).
............ L.Clay
M. D.
(Address).
........... G .......
Date 3/19
195
6 Winthrop Com Place of Burial or Cremation
Winthrop. Foss
DATE OF BURIAL. Mar.22 19.5.5
7 NAME OF
FUNERAL DIRECTOR
M.W.Kirby
ADDRESS
Winthrop Mass
Received and filed
MAY 20 1955
19
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
FATHER (City) .... So Hero Vermont.
(State or country)
19 MAIDEN NAME
OF MOTHER
Katie --
20 BIRTHPLACE OF
MOTHER (City).Milford N H
(State or country)
21
Informant
Mrs .... Doris ... Bergstron
(Address)
A TRUE COPY,
ATTEST!"
(Registrar of City or Town where death occurred)
DATE FILED
Mar 23
19 ...
55
()
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,
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
25M-3.53-909098
11 IF STILLBORN, enter that fact here.
12
AGE68
.Years
.Months.
Days
If under 24 hours
Hours ...
Minutes
13 Usual
Occupation:
Laborer
(Kind of work done during most of working life)
14 Industry
or Business:
Town of Winthrop
15 Social Security No ...
16 BIRTHPLACE (City)Quincy Mas's
(State or country)
10a If married, widowed, or divorced
HUSBAND of
Ida Gravelle
re maiden name of wife in full)
(or) WIFE of
9 COLOR OR RACE
(write the word)
8 SEX
Male
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDWidowed
(Husband's name in full)
weeks
17 NAME OF
FATHER
William B Orcutt
1
RECEIVED
TOir.
11.12
112
MAY 20
X
Suffolk
(County)
Lovoro
(City or Town) urover la or
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH ital
(City or town making return)
Registered No.
91
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
Alvotta Low na Tewksbury (Villians)
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.) 240 rleasant Ct.
St.
wir throp,
ass .
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years.
2
months.
days. In place of residence
.years.
months ..
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
march 21,
1955
(Month)
(Day)
(Year)
8 SEX
Pomale
9 COLOR OR RACE
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
4
idow d
4I HEREBY CERTIFY,
24
19.
to
or
20,
55
19.
death is said to
have occurred on the date stated above, at
INTERVAL BE-
DISEASE OR CONDITION
DIRECTLY LEADINGnchopneumonia
TO DEATH (a)
TWEEN ONSET AND DEATH 35hrs
11 IF STILLBORN, enter that fact here.
12
34
Years
9
Months.
20
Days
If under 24 hours
.Hours.
Minutes
13 Usual
Occupation :
Retired housewife
(Kind of work done during most of working life)
14 Industry
or Business:
own
16 BIRTHPLACE (City)
(State or country)
Nova Scotia
17 NAME OF
FATHER
Lewis . Willia 's
18 BIRTHPLACE OF
Cannot be learred
FATHER (City).
(State or country)
19 MAIDEN NAME
OF MOTHER
Helen N. Johnstone
Halifax
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
(va Scotia
21
John ! day es
Informant.m (Address) 179 Minthron
inthron
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
March 23,
........
1955
V. I. V
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
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, Ser 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 (E)-6-50.902253
7:02 .
PLACE OF DEATH
RM R-302 1
aralysis
itans
1952
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? no
If so, specify@ ......... bonne .... tely
(Signed
(Address)
Date winthrop
6 Place of Burial or Cremation
DATE OF BURIAL.
23,
19
7 NAME OF
FUNERAL DIRECTOR
Alfred I. Marsh
ADDRESS
174
inth .cu. ft. ,Winthrop
Received and filed
MAY 10 100 19
(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
Frederick Al est Low sbury
(Husband's name in full)
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
15 Social Security No.
PARENTS
.21
M. CD. .19 ...
(City or Town) 55
No.
(a) Residence. No. (Usual place of abode)
34
(Was deceased a
U. S. War Veteran,
if so specify WAR)
I last saw h
alive on
3:45 1.
m.
That I attended deceased
from
55
M
19
OTHER
SIGNIFICANT
CONDITIONS
AGE
RECEIVER
TO:
17
ל
6
MAY10
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)
2989
.92
[(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.)
17 Cutler St.
St.
Win throp Mass.
(a) Residence. No. (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 23/55
(Month)
(Day)
(Year)
8 SEX
F
9 COLOR OR RACE
10 SINGLE
(write the word)
MARRIED
WIDOWED Widowed
or DIVORCED
4 I HEREBY CERTIFY,
That I attended deceased from
March 7, 19 55.
to.
March .. 2.3.
1855
I last saw h .. @r ..... alive on ....
March ... 23
..... 195.5., death is said to
10a
If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Benjamin Sogoloff
isband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 74 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:
At Home
15 Social Security No ..
None
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF FATHER Bernard Sandler
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Ka ther ine Baker
20 BIRTHPLACE OF
MOTHER (City)
.Russi.a ....
Place of Burial or Cremation "sraet West (city of Town) .... Mass (State or country)
DATE OF BURIAL
March 25/55
19
21
Informant
(Address)
Bernard ... Gardner
7 NAME OF
FUNERAL DIRECTOR
Paul R Levine
Brookline Mass.
ADDRESS
Received and filed. 19
(Registrar of City or Town where deceased resided)
9 Mos
Due To
carcino atosis
Due To (c)
OTHER
SIGNIFICANT
Diabetesmellitus
5 Yrs
Major findings:
Of operations.
Recto sigmoid resection
Date of operation .... 1.2-3-52 ....
Was autopsy performed ?.
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
J ... G.Greenfield ..
M. D.
PARENTS
25M-10-53-910621
PLACE OF DEATH
RM R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
ANTE CEDENT (b) CAUSES (Address) 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, CONDITIONS
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
rectum with abdominal
INTERVAL BE-
have occurred on the date stated above, at. 8:2.5PM[. ... m.
TWEEN ONSET AND DEATH It he
Adenocarcinoma of
Registered No.
No.
Jewish
Memdial Hosp t.
Esther Sogoloff
(Was deceased a
U. S. War Veteran,
if so specify WAR)
A TRUE COPY
ATTEST: arles It Machen
(Registrar of City or Town where deatt fgutred)
March 28
DATE FILED 19
...... V. B. V
RECEIVED
TC
1.12
الاسماء
٠٠٦
6
MAY 2 1
ORM R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
25M· 10-53-910621
PLACE OF DEATH
Su folk (County)
Boston
(City or Town)
Lass. Memorial Hosp
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. 03111 93
f(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME Mrs. Christine Sheehan nee (Winters) (If deceased is a married, widowed or divorced woman, give also maiden name.).
St
Winthrop
(If nonresident, give city or town and State)
10 hrs.
.months ............ days. In place of residence ...
.... years.
.months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
18 SEX
Female
9 COLOR OR RACE
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Married
10a If married, widowed, or divorced
HUSBAND of
Michael J Sheehan
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12 147
3
1
AGE
Years
Months.
.Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
at home
15 Social Security No.
Boston,
16 BIRTHPLACE (City)
(State or country)
Lass
17 NAME OF
FATHER
Unknown
18 BIRTHPLACE OF
FATHER (City).
(State or country)
19 MAIDEN NAME
OF MOTHER
Unknown
20 BIRTHPLACE OF MOTHER (City) (State or country)
Michael J Sheehan
21
Informant
45 Shore Drive Winthrop
A TRUE COPY
ATTEST:
harker & Mackie
(Registrar of City or Town where death occurred)
DATE FILED
Mar 30 1955
.....
........
19
11
No. .
Length of stay: In place of death ..
......
.. years ..
3 DATE OF
DEATH
Mar
25
(Month)
(Day)
4 I HEREBY CERTIFY
3/25
....
ANTE
Due To
CEDENT (b)
CAUSES
Due To
(c)
SIGNIFICANT
Major findings:
Of operations
What test confirmed diagnosis ?.
Autopsy
6
Winthrop
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 of town in which the deceased resided as soon as possible,
CONDITIONS
with Acidosis
55
(Year)
That I
attended deceased, from
1955
11
to
a .m.
3/25
19 .. 5.5.
I last saw
alive on
3/25
195.5 .. , death is said to
have occurred on the date stated above. at 9.3@ .... p.
.m.
INTERVAL BE-
TWEEN ONSET AND DEATH
OTHER
Diabetes Mellitus
Yo's
Date of operation
.Was autopsy performed?
No
5 Was disease or injury in any way related to occupation of deceased ?.
If so, specifal .....
acob Leman Jr.
(Signed).
(Address) Lass Memorial Homp 3/26
55
M. D.
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
March 29
55
7 NAME OF
Ernest P Caggiano
FUNERAL DIRECTOR
147 Winthrop st Winthrop
ADDRESS
Received and filed 19
(Registrar of City or Town where deceased resided)
PARENTS
(Was deceased a
U. S. War Veteran.
if so specify WAR).
(a) Residence. No. 45% shore Drive (Usual place of abode)
DISEASE OR CONDITION
DIRECTLY LEADING
lobar pneumonia
TO DEATH (a)
right upper
& left lower lobe lwk
Housewife
RECEIVED
OF
TOW
11 12
1
n
-
MAY31 AN
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
Bos. to (City or town making return)
Registered No.
3743 01
No.
Mass. General Hospt.
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME. Joseph A Smith (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.
20 Pleasant St
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
.... years
months ...
2 .... days. In place of residence ... ].Q .. years.
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
March 28/55
8 SEX
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWEDarri ed
or DIVORCED
(write the word)
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I
attended deceased from
March 27 19 55.
to
March .. 2819 ... 55.
I last saw h .... j.m ... alive on.
March ... 28 ... 19.55, death is said to
(or) WIFE of.
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Myocardial infarction
anterior
2 Days
11 IF STILLBORN, enter that fact here.
12
AGE65
Years ..
Months.
.. Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation:
Banafor.
14 Industry
or Business:
Life Insurance
15 Social Security No ..
None
16 BIRTHPLACE (City)
(State or country)
East Boston Mass.
OTHER
SIGNIFICANT
CONDITIONS
Diabetes mellitus
8 Yrs
Major findings:
Of operations
Date of operation.
Was autopsy performed?
Yes
What test confirmed diagnosis?
autopay
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed).
CL Clay
M. D.
(Address)
Magg General HospHate 3 28 1955
6 Place of Burial or denthar p Cem-Winthe0; Town)
DATE OF BURIAL.
march 30/55
19
7 NAME OF
FUNERAL DIRECTOR
M W Kirby
ADDRESS.
Winthrop Mass.
Received and filed. 19
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Irciand
19 MAIDEN NAME
OF MOTHER
Rose Ennis
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21
Informant.
(Address)
Robert Smith
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED March 31/55
19
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
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
25M-10-53-910621
ANTE
CEDENT (b)
Due To
Coronary heart disease
5 Yrs
Due To (c)
10a If married, widowed, or divorced
HUSBAND of.
Madeline ... 0!Donnell
(Give maiden name of wife in full)
have occurred on the date stated above, at.
.1.1 .: 48A .. m.
INTERVAL BE-
TWEEN ONSET AND DEATH
(Kind of work done during most of working life)
17 NAME OF
FATHER
Robert Smith
RM R-302 1
(Usual place of abode)
Win throp
Mass .
RECEIVED
TOW
11 12.
1
3
5
6
THROP
AM
MAY31
ORM R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
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
25M-10-53-910621
X
PLACE OF DEATH
SUMOLK (County) ROS!
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
MOSTON
(City or town making return)
Registered No.
3211
95
f(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME. Baby Boy Paul Schlichting (If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a U. S. War Veteran. if so specify WAR) No
(a) Residence. No. Usual place 19 Pauline St ." Winthrop St. (If nonresident, give city or town and State)
Length of stay: In place of death .. .......... years ..... .. months .... ] ...... days. In place of residence. ........... years. .months .days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Month)
3(Day)
1255
4 I HEREBY CERTIFY,
That I
attended deceased
from
... Mar ....... 29 ......
19.55 ....
to Mar 30
19.
55
I last saw him alive on Mar 30
19.
55death is said to
have occurred on the date stated above, at .. 1 0.1.5
.. m.
INTERVAL BE-
TWEEN ONSET
AND DEATH
11 IF STILLBORN, enter that fact here.
4 days 12
AGE
Years.
Months.5.
Days
If under 24 hours
Hours .....
.Minutes
13 Usual
Occupation :.
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Winthrop
Lass .
17 NAME OF
FATHER
Henry Schlichting
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Roxbury
19 MAIDEN NAME
OF MOTHER
Kathryn Pimental
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
H ...... Father
7 NAME OF
FUNERAL DIRECTOR E. P. Caggiano
ADDRESS
Winthrop Mass
Received and filed.
JUN 1 1955
19
(Registrar of City or Town where deceased resided)
5 days
Due To Prematurity (c)
Generalized icterus toxic
OTHER SIGNIFICANT CONDITIONS
Major findings:
Of operations.
Date of operation
.. Was autopsy performed ?.... Yes
What test confirmed diagnosis?
PARENTS
5 Was disease or injury in any way related to occupation of deceased ?.... NO.
If so, specify.
(Signed)
C.J. Tremblay
M. D.
(Address) St. Elizabeth Hoge Mar31 1955
Winthrop Com Winthrop Mass. Place of Burial of Cremation (City of Town)
DATE OF BURIAL. Mar 31
21
Informant
(Address)
E COPY Charles H. mackie
ATTEST.
(Registrar of City or Town where death occurred)
DATE FILED
Apr. 4
..........
19
55
8 SEX
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single -
10a
If married, widowed, or divorced
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) Septicemia
ANTE
Due To
CEDENT (b) .... Aspiration pneumonia
No.
St ...... Elizabeth !. s .... Hosp.
RECEIVED
TOR-
1
6 5
JUN-1 AM
X
PLACE OF DEATH
Suffolk
(County)
Boston
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.
3633
96
J (If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME
Corl.L.Ellis
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 962 Shirley ... St ......
St.
(ff 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
(Month)
April 11/55
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
April 11 15
I last saw h .............. alive on
April 11 ... "'S ..... death is said to
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
.Years.
. Months.
Days
If under 24 hours
, Hours
Minutes
3 Hra
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Boston Hass.
17 NAME OF
FATHER
Carl Ellis
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Swampscott.Mass ..
19 MAIDEN NAME
OF MOTHER
Lucille Lacouture
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Lynn Mass.
6
Place of Bu
St.Jean Baptiste ... Com Lynn Lass
(City of Town)
DATE OF BURIAL
April ... 12/55
19
21
Informant
(Address)
Mrs ... L ... Ellis
A TRUE COPY
Markes Hi. Machu
ATTEST:
(Registrar of City or Town where death occurred)
April 14/55
DATE FILED
.19
X
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
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-10-53-910621
7 NAME OF
FUNERAL DIRECTOR
A J. St. Laurent
ADDRESS
Lynn Mass.
Received and filed
JUN 9 1955
19
(Registrar of City or Town where deceased resided)
8 SEX
9 COLOR OR RACE
W
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
have occurred on the date stated above, at
m.
INTERVAL BE- TWEEN ONSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a).
Premature
Labor
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?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed).
B. Parvey
M. D.
(Address)
Boston MaBs
Date ........
PARENTS
ORM R-302 1
(City or Town)
No.
Kenmore Hos pt.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(Usual place of abode)
5.5
RECEIVED
TOTO
11 12 1
6
JUN -- 9 ?'1
X
Suffolk
(County) Rovore
(City or Town) Grover anor No. samuel Loster hinnear
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH tal
(City or town making return)
Registered No.
9.7
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.)
107 Bowdoin treot
Tint
Ot.if so specify WAR) ,
(a) Residence. No. (Usual place of abode)
3
40
(If nonresident, give city or town and State)
Length of stay: In place of death
years
3
months. ......
days. In place of residence. .years months .. .. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
(Day)
(Year)
4 I HEREBY, CERTIDY,
That, L, attended deceased from
19
I last saw h ...
......
.. alive on
3:45 A.
death is said to
have occurred on the date stated above, at .m.
DISEASE OR CONDITION,
DIRECTLY LEADING
TO DEATH (a)
Uremia
INTERVAL BE- TWEEN ONSET quay's
11 IF STILLBORN, enter that fact here.
12 AGE Years
Months.
Days
If under 24 hours
.. Hours ..
.. Minutes
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry or Business:
Winthrop School ept.
15 Social Security No ..
16 BIRTHPLACE (City).
(State or country)
17 NAME OF
FATHER
William Kinnear
18 BIRTHPLACE OF FATHER (City) .. (State or country)
19 MAIDEN NAME.
OF MOTHER
Lovenia Cole Late
20 BIRTHPLACE OF
MOTHER (City) ......... uswich
(State or country)
21 L'lbricre Y.
Do Icher
Informant.
(Address)-30-incel .....
·,
Fint rop
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
April
26,
55
DATE FILED
19
(Registrar of City or Town where deceased resided)
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