USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1956 > Part 14
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12
AGE
31 Years
.Months ..
.Days"
If under 24 hours
Hours .....
Minutes
13 Usual
Occupation :.
housework
(Kind of work done during most of working life)
14 Industry
or Business :
own home
15 Social Security No ...
030-03-6080 A
16 BIRTHPLACE (City)
(State or country)
Newfoundland
St ...... John ..
17 NAME OF
FATHER
William Walsh
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Newfoundland
19 MAIDEN NAME
OF MOTHER
Jane Angell
20 BIRTHPLACE OF MOTHER (City). (State or country) Newfoundland
21 Lillian Mitchell
Informant
(Address) 276 Princeton St. E. Boston
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Walter & Haberg . (Signature of Agent of Board of Health or other)
Mealite Office 3/6/56
(Official Designation) V
(Date of Issue of Permit)
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
does not mean e of dying, heart failure, etc. It means se, or compli- which caused
ons, if any, gave rise to cause (a). the under- cause last.
-
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
MASSIVE PLEUral EFFusion 7 days. N-ChEst.
Was autopsy performed? What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed) Domini Menuas Stuffier M. D.
(Address)
21 Breed LIEB Date Feb. 29 1956
6 Holy ..... Gross Place of Burial or Cremation March 3 19: .56
Malden
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR.
Frederick J. Magrath
East Boston
ADDRESS
MAR 6 1956 19
Received and filed
29 1956 (Year)
(Month)
(Day)
4 I HEREBY CERTIFY,
to ....
56
19.
That I attended deceased from
FEB. 20.
56
FEB.
29
I last saw hCfalive on
FEB.29, 1956, death is said to
have occurred on the date stated above, at 1255 P.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Coronary Thrombosis
INTERVAL BETWEEN ONSET AND DEATH
minutes
Due
GENERAL ARTERIOSCLEROSIS
(h)
MRS.
PARENTS
100M-11-55-916145
[ R-301A 1
No.
Winthrop Community Hospital
CERTIFICATE OF DEATH
Registered No.
$(If death occurred in a hospital or institution.,
St. { give its NAME instead of street and numher)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
NO
(a) Residence. No. (Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Fil3
Elizabeth A. Scanlan
(Registrar)
tions contrib- death but not o the terminal ondition given
Chapter 137, 1954, requires ns to print or e
cause or of death on ertificates.
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- te"n, 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, 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 from disease unrelated to aný form.of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons whof 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
ORM R-302 1
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,
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.
:34
34
1001
[(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME ..
John H Glock
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 896 Shirley St.
St.
Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In place of death. .......... years 5
months. days. In place of residence2 .. years.
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Month)
Jan. 26/56
Da
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
156.
....
to ..
Jan ...... 26, 156.
I last saw himg.
.alive on.
Jan .....
26 .... 156
death is said to
have occurred on the date stated above, at.
1 PM.
m.
INTERVAL BE-
11 IF STILLBORN. enter that fact here.
12
AGE
.59.Years.
Months.
Days
If under 24 hours
Hours.
Minutes
staphylococcus aureus
Dre Tter ocoli ti s
ANTE
CEDENT
CAUSES
staphylococcus aureus
Due To (c)
OTHER
SIGNIFICANT PetitMal
CONDITIONS
attacks
Major findings:
Of operations.
Date of operation.
aut is ytopsy performed ?.
What test confirmed diagnosis?
5 Was disease or injury in
y way related to occupation of deceased?
if so, specify.
(Signed).
Mass .General Hospt
.Date
1=26
195
6
Winthrop. Com. Winthrop Mass. Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Jan.30/56
19
21
Informant.
(Address)
H. M Glock
7 NAME OF
FUNERAL DIRECTOR
M W Kirby
ADDRESS
Winthrop Mass
Received and filed
APR 5 1956
19
(Registrar of City or Town where deceased resided)
2 Weeks
14 Industry
or Business:
Automobile
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Cambridge-Mass ..
17 NAME OF FATHER William H Glock
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Maryland
19 MAIDEN NAME
OF MOTHER
Bertha Chute
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
A TRUE COPY
COPY Www.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Feb.3/56
19
V
8 SEX
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
10a If married, widowed, or divorced
HUSBAND of.
Harrietta ... M.Wilson
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH Septicemia
TWEEN ONSET AND DEATH
Week
13 Usual
Occupation :
Mechanic
(Kind of work done during most of working life)
PARENTS
(Address)
34 Days
25M-10-53-910621
I.S.
No. .
Mass. General Hoapt.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
W w #1
(Usual place of abode)
RECEIVED
TOW.
OF
11 92
65
'THROP.
AM
P
APR-5
Sept. 19,1918 Dec. 9,1918 Private Co.A S.A.T.C. University of Vermont 21:61196
RM R-305 1
PLACE OF DEATH
(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)
1003 35
Registered 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.)
92 Marshall 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
3 DATE OF
DEATH
Jan.30/56
(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.) Multiple fractures auto accident
pedestrian at Boston 1-14-6
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
M
10 COLOR OR RACE
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
11a If married, widowed, or divorced
Fannie Placco
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
77 Years
Months.
Days
If under 24 hours
Hours.
Minutes
14 Usual
Occupation :.
Retired
(Kind of work done during most of working life)
15 Industry
or Business:
Barber
16 Social Security No.
None
17 BIRTHPLACE (City).
(State or country)
Italy
18 NAME OF FATHER Salvatore Mancuso
19 BIRTHPLACE OF
Italy
FATHER (City).
(State or country)
20 MAIDEN NAME
OF MOTHER
Grace Rinaldi
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
22 Informant. (Address)
Wife
A TRUE COPY.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Feb.3/56
19
........
25M.5.52.907046
In ..
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 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-305 to the clerk of the city or town in which the deceased resided as soon as possible
(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? ....
6 Was disease or injury in any way related to occupation of deceased? ...
If so. specify
(Signed)
Richard Ford
M. D.
(Address) Date 1-30 19 56
Winthrop Cem-Winthrop Mass.
7 Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL.
Feb.2/56
19
8 NAME OF FUNERAL DIRECTOR Winthrop Mass
ADDRESS
Received and filed. 4-1-56 19
(Registrar of City or Town where deceased resided)
PARENTS
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19
Where did Injury occur ?.
SUFFOLK duBOSTON.
Boston City Hospt. No.
Carmine Mancuso
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. (Usual place of abode)
E P Caggiano
...
RECEIVED
OF TOW
11.12 1
C:
6
7HRC
PPR-6 AM
RM R-305 1
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
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
25M.5-52.907046
PLACE OF DEATH
SUFFOLX 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 1
(City or town making return)
1003
Registered No.
Bost on City Hospt.
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.)
92 Marshall St.
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
3 DATE OF
DEATH
Jan. 30/56
(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.) Multiple fractures auto accident
pedestrian
at Boston Jan-14:56
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
M
10 COLOR OR RACE
W
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
11a If married, widowed, or divorced Fannie Placco
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
Years
77
Months.
Days
If under 24 hours
.. Hours .......
.Minutes
14 Usual
Occupation :.
Retired Barber
(Kind of work done during most of working life)
15 Industry or Business :.
16 Social Security No.
None
17 BIRTHPLACE (City)
(State or country)
18 NAME OF FATHER Salvatore Mancuso
19 BIRTHPLACE OF
FATHER (City).
(State or country)
Italy
20 MAIDEN NAME OF MOTHER Grace Rinaldi
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
Winthrop Cem Winthrop Mass
·
7 Place of Burial, or Cremation. Feb. 2/56
/(City or Town)
DATE OF BURIAL. 19
8 NAME OF
FUNERAL DIRECTOR
E P Caggiano
ADDRESS Winthrop Mass
Received and filed. 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)
Richard Ford
M. D.
(Address)
Date
1-30 19 56
22
Informant
(Address)
Wife
J
A TRUE COPY.
ATTEST:
100000
(Registrar of City or Town where death occurred) Feb. 3/56
DATE FILED
19
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
(Specify type of place)
Injury
(How did injury occur?)
Nature of
Injury
While at work?
.Was autopsy performed?
No.
Carmine Mancuso
(Was deceased a
U. S. War Veteran.
if so specify WAR)
(a) Residence. No. (Usual place of abode)
Winthrop Mass
Italy
OF TO !.
1.12
6
APR-6 IM
×
PLACE OF DEATH
Norfolk. (County)
Foxborough
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(cifaxharghghg this return)
36
Registered No.
$(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
Louise Madona
(If deceased is a married, widowed or divorced woman, give also maiden name.)
St
Winthrop , Mass.
(If nonresident, give city or town and State)
.years ..... 5 .... months.2
.. days. In place of residence. Unkears.
.. months.
... days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX Female
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
single
10a If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
26Years.
Months
20Days
Hours ........ Minutes
13 Usual
Occupation :.
None
(Kind of work done during most of working life)
14 Industry
or Business :.
15 Social Security No ...
16 BIRTHPLACE (City)
(State or country)
Mass.
E .... Boston,
17 NAME OF
FATHER
Louis Madona
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
Filomena Chicarelli
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Italy
21
Informant
Foxborough State Hosp records,
(Address)
Foxborough, Mass
A TRUE COPY ATTESAdred J Shannon AgtBdHlth 2-27-56. (Registrar of City or Town where death occurred)
DATE FILED 19
50M.11-55.916145
2 FULL NAME. (a) Residence. No .. 123 Locust (Usual place of abode) Length of stay: In place of death ... MEDICAL CERTIFICATE OF DEATH 3 DATE OF DEATH February 25. 1956 (Month) (Day) (Year) I last saw h .. @@live on Feb ...... 24 19. have occurred on the date stated above, at 8:05 .. m. DEATH WAS CAUSED BY: IMMEDIATE CAUSE (a) .Bronchopneumonia Due To (1)) Due To (c) CONDITIONS 6 Winthrop Ce m. Winthrop Mass Place of Burial or Cremation (City or Town) DATE OF BURIAL 2-28-56 7 NAME OF FUNERAL DIRECTOR Maurice W Kirby resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town OTHER SIGNIFICANT Congenital-mal development, blind idiot.
Was autopsy performed ?. ... yes What test confirmed diagnosis ?. Clin.Lab.& Autopsy.
5 Was disease or injury in any way related to occupation of deceased ?. no If so, specify
(Signed) H Gerald Wagar M. D.
(Address)
Foxborough, Mass.
Date.
2-27-569
19
ADDRESS. Winthrop, Mass.
Received and filed.
WAR 1.3 1956
19
(Registrar of City or Town where deceased resided)
4 1 HEREBY CERTIFY,
That I attended deceased from
Sept. 23 ..... , 19.48, to ....... Feb ..... 25 1956
.56 death is said to
INTERVAL BETWEEN ONSET AND DEATH
If under 24 hours
(Was deceased a
U. S. War Veteran,
if so specify WAR)
no
No. Foxborough State Hospital
[ R-302 1
A, TILLLL VAFADING DLAVA INA - THIS IS A PERMANENT RECORD
4
5
THROP
MAR13
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 Internetional Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
PLACE OF DEATH
Sullek (County)
M R-303 A 1 Wenthub (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be fied for burial permit with Board of Health or its Agent.
Registered
37
125 Hermon St No. William R Mac Phael 2 FULL NAME.
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. W.W.1 if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.) 125 Hermon St. Withnos
(a) Residence. No. (Usual place of abode)
15
Length of stay: In place of death.
years
months ..........
days. In place of residence.
... years
months.
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
March - 6 -1956
DEATH
(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 ) Hyperteuren Heart Disease
... acute Myocardial Infarction
...
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Male
10 COLOR OR RACE
White
MARRIED
WIDOWED
or DIVORCED
Married
11a If married, widowed, or divorced-
trude Eldredge
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12 IF STILLBORN. enter that fact here.
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