USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1955 > Part 52
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Howard J. Regard
ADDRESS
Received and filed AUG 2 1585
19
(Registrar)
PARENTS
5 Was disease or injury in any way related to occupation of deceased? No
arthur@murray
(Signed)
Winthrop Board of Her ate Bo July 1955
.. , M. D.
6
Winthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL.
Aug. 2.
1955
2
To be filed for burial .parmit with Board of Health or its Agent.
154
Registered No.
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, if so specify WAR)
W.W. 11
(write the word)
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Natural Causes
ANTE
To Presumably Coronary
CEDENT (b)
CAUSES
Occlusion
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Major findings:
Of operations.
Esophageal Ulcer
Date of operation.
March 1955 Was autopsy performed ?.
NO
What test confirmed diagnosis ?.
Operation
Winthrop
10a If married, widowed, or diversean Waters
HUSBAND of.
AGE
Years
That I
attended deceased from
30
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
74,5,
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 dercased. 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 dicd, 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, eightcen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and ninetcen hundred and seventecn. 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 hoard, 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 eertifying the eause 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, See. 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 pr 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 from disease unrelated to any form ofinjury
(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 ean 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, eook-hotel, etc. For a person who had no occupation whatever write none.
.
SPACE FOR ADDITIONAL INFORMATION
Archibald J Dałzell
DATE OF ENTERING MILITARY SERVICE Dec. 11, 1917
DATE OF DISCHARGE Sept 30. 1921
RANK, RATING Yeo.3c
ORGANIZATION AND OUTFIT ...... U. S. Navy
SERVICE NUMBER
130-12-40
-
ORM R-302 1
PLACE OF DEATH
Pinellas
Indian Rocks Beach Florida
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
(City or town making return)
Registered No. 1.55
f(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
ANNIE Bailie Cate
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 15 Faun Bar Ive.
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
March
15
1955
8 SEX
9 COLOR OR RACE
10 SINGLE MARRIED WIDOWED of DIVORCED
(write the word)
........ .........................
STATE BOARD OF HEALTH BUREAU OF VITAL STATISTICS
NON RESIDENT
STATE FILE NO.
DIRTH NO
1. PLACE OF DEATH a. COUNTY
CODE NO. 62 -XX
2. USUAL RESIDENCE (Where deceased lived, It institution; Toutdoute before .. STATE b. COUNTY
Pinellas
(if outside corporate limits, write RURAL)
C. CITY
TOWN
Winthrop
and's name in full)
re.
1. NAME OF DECEASED (Type or Print)
« (First)
h (Middle)
e. (Last) Cato
4. DATE OF DEATH
(Month)
(Day) {Yat)
5. SEX
2
Female
White
7. MAREIED, NEVEE MARRIED, WIDOWED, DIYORÇED (Sperity) Married
December 15, 1886
Ila. USUAL OCCUPATION(Gir kind of surh 10b. KIND OF BUSINESS OE IN- Goto during mest of parking ura, even if rotiret) Home VAker
DUSTRY
11. BIRTHPLACE (Male er foreign country) Dublin, Ireland 50
12. CITIZEN OF WHAT COUNTRY? USA
11. FATHER'S NAME
14. MOTHER'S MAIDEN NAME Tpknown
(Lugono T. Cats)
william Ballle
15. WAS DECEASED EYEE IN U. S. ARMED FORCES? (TEL. MA, or sknova) |(if you, gire wir or dates of service)
14. SOCIAL SECURITY NO.
17. INFORMANT'S SINATU E
ADDRESS 15 PaunBar Aver, Winthrop, Haus.
MEDICAL CERTIFICATION
INTERVAL BETWEEN
I. DISEASE OR CONDITION DIRECTLY LEADING TO DEATH" (a
.
ONDET M
ANTECEDENT CAUSES
DUE TO
the mode of dying, meh as keert fallurs, stkmia, ele. It means ing the underlying cques last.
DUE TO Nel
templestien v & is & |II. OTHER SIGNIFICANT CONDITIONS
Conditions contributing to the death but not related to the disease or condition ocusing death,
4201.26
11e. DATE OF OPERA- Th, MAJOR FINDINGS OF OPERATION
20. AUTOPSY?
TION
YES
NO Ci
(Ipeetty]
21b. PLACE OF INJURY (a.p. to or tive)
21c. (CITY OR TOWN
(COUNTY)
{STATE}
I Pret Kals RURALI
21d. TIME OF
(Mentk) (Day ( Your)
Zle INJURY OCCURRED
21. HOW DID INJURY OCCUR7
INJUET
b&hgeby cortily that I attended the deceased from
19, 10 , 10_, that I last saw the deceased
I, from the causes and on the date stated above.
201. ADDRESS
3/16/35
Me. BURGL CREMA- MS. DATE TION, RIA
Me. NAME OF CEMETERY OR CREMATORY
2d. LOCATION (City, toini, er county
3-20-55
Unknown
Winthrop
Massachusett
7 NAME OF FUNERAL DIR DATE RIC'D BY LOCAL REGISTRAR'S SIGNATURE
ES FUNERAL DIRECTOR'S SIGNATURE
ADDRESS
3-16-1955
Rahut & manuel Kill ERE95
(Registrar of City or Town where death occurred)
Received and filed.
AUG- 25.1955
19
DATE FILED
19
(Registrar of City or Town where deceased resided)
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
No. 2 FULL NAME. 3 DATE OF DEATH 4 I HEREBY I last saw h have occurred on DISEASE OR CO DIRECTLY LEA TO DEATH (a). ANTE Due To CEDENT (b) CAUSES Due To (c) OTHER SIGNIFICANT CONDITIONS Major findings: Of operations. What test confirme 5 Was disease or inj If so, specify (Signed) (Address) 6 Place of Burial DATE OF BUR 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, Date of operation ...
den name of wife in full)
Massachusetts
Suffolk).
b. CITY OF TOWN Indian Rocks Paach
C. LENGTH OF STAY (in thần pince) ₿ daya
d. STREET
tit ram! rive location)
d. FULL NAME OF (If not in bempital er institutlen, give street address er location) HOSPITAL OR INSTITUTION
19510 Oulf Boulevard (On beach) px. 15 FaunBar Avenue
March 15, 1955
6. COLOE OR RACE
A. DATE OF BIRTH
9. AGE (In TORT) IF ONDER I THAD birthday) Menthe
Days
If under 24 hours Hours ... .Minutes
done during most of working life)
Own Home
Tone
10. CAUSE OF DEATH Enter only one cause per line for (a), (b).
Morbid conditions, if any, giving viss to the above cause (a) stat-
Za. ACCIDENT QUICIDE HOMICIDE
3 055 19.55, and that death occurred at
A SIGNATURE
Dunedin, Florida
ADDRESS
TEOF DEATH
11633
REGISTRAR'S NO
(Was deceased a U. S. War Veteran, if so specify WAR)
(City of Town) 19510 Gulf Boulevard (on beach)
CERTIFICATE OF DEATH
管好儿童 AT NOT WHILE
Baille
.
-
ومك
٢٠ ٠
4
٥
D
.
٠٠
4
ORM R-302 1
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 WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
X
PLACE OF DEATH
Middlesex (County)
Waltham
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
Waltham
(City or town making return)
Registered No.
361
156
Daniel J. Danahy
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.) 53 Thornton park
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)
(Day)
(Year)
male
9 COLOR OR RACE
whito
MARRIED
WIDOWED
or DIVORCEDSingle
4 I HEREBY CERTIFY,
May 22
55
19
July
1
55
death is said to
have occurred on the date stated above, at.
m.
INTERVAL BE- TWEEN ONSET AND DEATH
DIRECTLY LEAPUAchopneumonia
TO DEATH (a).
3ds
ANTE
Due To
CEDENT (b)
CAUSES
Due To (c)
Mental deficiency life
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation
Was autopsy performed? no
What test confirmed diagnosis ?.
90
5 Was disease or injury in any way related to occupation of deceased?
If so; Specify .....
Penfold
(Signed) averloy , riass"
.Date.
7-7
M.C.D.
(Address)
Holy
6
Cross cerl., Maiden
Place of Burialor Cremation
DATE OF BURIAL .. July 4
(City or Town) 55
7 NAME OF
FUNERAL DIRECTOR ...
Everett, Mass.
Received and filed.
AUG 17 1955
19
(Registrar of City or Town where deceased resided)
PARENTS
21
WEF School
Informant (Address) averloLass
paragon
DATE FILED
July 11
55
X
!
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
156
AGE.
Years.
3
Months- 3
... Days
If under 24 hours
Hours ......
Minutes
13 Usual
Occupation :.
ilone
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No.
16 BIRTHPLACE (CityWerett
(State or country)
17 NAME OF
FATHERJeremiah Danahy
18 BIRTHPLACE OF
FATHER (City).
(State or countrDre land
19 MAIDEN NAME OF MOTHERIargaret Howard
20 BIRTHPLACE OF
MOTHER (City)
(State or countrireland
25M-3.53-909098
July
2, 1955
8 SEX
attended deceased from
55
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
I last saw h
alive on
12:25am
DISEASE OR CONDITION
10 SINGLE
(write the word)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
Winthrop
Mass
(a) Residence. No. (Usual place of abode)
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
(City of Town) Walter E. Fornald State School No.
CERTIFICATE OF DEATH
A TRUE COPY ATTEST: (Registrar of City or Town where death occurred)
J. J] Curnnane
ADDRESS
That
July 2
MANUIN RESERVED FOR BINDING
RECEIVED
TOW
. 11:11
AUG1'.
RM R-302 1
-
Rovere.
(City or Town)
Grover Manor Hospital
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Dovere
(City or town making return)
Registered No.
157
"(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME ..
Tev. Ralph Moore Hamon
(If deceased is a married, widowed or divorced woman, give also maiden name.)
-
(Was deceased a
U. S. War Veteran,
if so specify WAR)
St. ... Winthrop ..
Ifass.
(If nonresident, give city or town and State)
Length of stay: In place of death ...
.years.
5
... months.
days. In place of residence 1 0
.. years.
.. months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Nale
White
9 COLOR OR RACE
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDi doved
10a If married, widowed, or divorced
HUSBAND of
Elgie C. Walbern
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.2
..... Years2
Months.8
Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation :.
(Kind of work done during most of working life)
14 Industry
or Business:
iscopal Church
15 Social Security No ....... L'one
16 BIRTHPLACE (City)incoton
(State or country)
Carolina
17 NAME OF
FATHER
Tameg Hopper
18 BIRTHPLACE OF
FATHER (City) Cannot .bo ..... loarnod ..........
(State or country)
19 MAIDEN NAME
OF MOTHER
Claudia (Cannot bc
learned)
20 BIRTHPLACE OF
MOTHER (City) Cannotle Loanod
(State or country)
21
Informa
Rev ...... John .... C ...... Harpor
(Address)
A TRUE COPY
ATTEST:
(Registrar of City or Towd Where death ostused)
DATE FILED
July
6
1.55
(Registrar of City or Town where deceased resided)
PARENTS
25M-(B)-11-51.905807
X
PLACE OF DEATH
No.
(a) Residence.
No.
231 Bowdoin
(Usual place of abode)
3 DATE OF
DEATH
July
40
(Month)
(Day)
4 I HEREBY CERTIFY.
Sept.
54
I last saw
alive on
im
ANTE
Due To
Generalized
CEDENT (b)
Due To
(c)
OTHER
SIGNIFICANT Fracture ..... loft .... hip
CONDITIONS
Major findings:
Of opera
Hip ... nailing
What test confirmed diagnosis?
Clinical
6
Winthrop
DATE OF BURIAL
Copies of returns of deaths which occurred in your city of town in case the deceased resided in another city of 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
Arteriosclerosis
That I attended deceased from
19.
to
July 4
65
July
1
.55
death is said to
have occurred on the date stated above,
12:35 P.m.
INTERVAL BE-
TWEEN ONSET AND DEATH
yrs
7 mo .
5 Was disease or injury in any way related to occupation of deceased? 10
If so, specify .....
(Signed) arthur C.
Murray
M., D.
(Address).i.nthrop.
Date ..
7/5/95
Winthrop
Place of Burial or Cremation (City or Town)
July
6
155
7 NAME OF
FUNERAL DIRECTOR
Howard Reynolds
Winthrop, Dass .
ADDRESS
Received and filed. AUG .12.1953 19
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
M.s.
Suffolk
(County)
1955
(Year)
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) Cerebral Arteriosclerosis
Date of operation CC 11, 19 Was autopsy performed? 110
RECEIVED
TOW
OF
11.12
1
NI !- 33
4
IN
AUG12 AH
M R-305 1
PLACE OF DEATH
SUFFOLL BOSTON (County)
(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 returd) 5 8
Registered No.
6353
j(If death occurred in a hospital or institution, XX\ give its NAME instead of street and number)
2 FULL NAME
BARNET LEIBOVITZ
(If deceased is a married, widowed or divorced woman, give also maiden name.)
18 Cross
St.
Winthrop, Mass
(If nonresident, give city or town and State)
-
-
1
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July.
6
1955
(Month) (Day)
(Year)
9 SEX
M
10 COLOR OR RACE
W
11 SINGLE
(write the word)
MARRIED
WIDOWED
of DIVORCED Married
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.) Arteriosclerotic heart disease
11a If married, widowed, or divorced
HUSBAND of.
Mae Solomon
(or) WIFE of.
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AGE
Tears
Months.
.Days
If under 24 hours
Hours
.Minutes
14 Usual
Occupation:
Laundry proprietor
(Kind of work done during most of working life)
15 Industry
or Business:
Royal White Laundry
16 Social Security No.
024-05-7764
17 BIRTHPLACE (City).
(State or country)
Russia
18 NAME OF
FATHER
Max Leibovitz
19 BIRTHPLACE OF
FATHER (City).
(State or country)
Russia
20 MAIDEN NAME
OF MOTHER
Riva Boyarsky
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
7 Ohel Jacob Com
Woburn, Mass
Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL ..
19
55
22
Informant
(Address)
Son
8 NAME OF
FUNERAL DIRECTOR
A ... G.o.lov
Brookline ,Mass
ADDRESS.
Received and filed. AUG. 16 1955 19
(Registrar of City or Town where deceased resided)
PARENTS
6 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
R.Ford
M. D.
(Address)
(Specify type of place)
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed?
25M-5-52-907046
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 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
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?
Manner of
Date 7/7
19.55
Jul 7
A TRUE COPY.
DE Larles H. Mackie
ATTESTI
(Registrar of City or Town where death occurred)
DATE FILED
Jul 11
1955
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death ... years. months. days. In place of residence ............ years. .months. .days.
818 Harrison "ve. No.
(Give maiden name of wife in full)
60
RECEIVED
OF TOWI
1
1
INTIL.
AUG15
×
PLACE OF DEATH
SUFFOLK BOSAMMY
(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.
69.85.50
J(If death occurred in a hospital or institution, St. \ give its NAME instead of street and number)
2 FULL NAME
JOHN J COLLINS
(Was deceased a
WW I
(If deceased is a married, widowed or divorced woman, give also maiden name.)
75 Buchanan
.....
St.
Winthrop .....
.. Ma.s.s
(If nonresident, give city or town and State)
Length of stay: In place of death
.......... years.
months]7 days. In place of residence 33 years.
......
.. months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
27
1955
(Day)
ThatVA
attended deceased from
7/27
19 ..... 55
I last saw h ......... alive_on ....
19 ..... , death is said to
have occurred on the date stated above, at2 :00p
.m.
INTERVAL BE-
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE ... 5.9.Years ..
.8.Months.28 ... Days
If under 24 hours
Hours ...
.Minutes
13 Usual
Clerk
Occupation :.
(Kind of work done during most of working life)
14 Industry
or Business:
US Army Base
15 Social Security No.
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