Town of Winthrop : Record of Deaths 1956, Part 87

Author: Winthrop (Mass.)
Publication date: 1956
Publisher:
Number of Pages: 534


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1956 > Part 87


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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14 Trident Ave


Winthrop, Mass


S


(If nonresident, give city or town and State)


Length of stay: In place of death .........


.. years.


months.


2 days. In place of residence LIO.


.. years.


months.


... days.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX M


9 COLOR


W


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


Married


10a If married, widowed, or divorced.


HUSBAND of


Ann Phillips


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE.7.Z ... Years.


Months ............ Days


If under 24 hours


Hours .....


.. Minutes


13 Usual


Occupation :


Grocer


retired


(Kind of work done during most of working life)


14 Industry


or Business:


15 Social Security No.


16 BIRTHPLACE (City)


(State or country)


Russia


17 NAME OF


FATHER


Morris Goldman


18 BIRTHPLACE OF


FATHER (City)


(State or countr


Russia


19 MAIDEN NAME OF MOTHER Annie --


20 BIRTHPLACE OF MOTHER (City) (State Russia


Wife


21 Informant (Address)


A TRUE COPY


ATTEST:


Charles N.7


(Registrar of City or Town where death occurred)


DATE FILED


DỰc


18


1956


VAJ


(c) Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased


2 FULL NAME Max Goldman (a) Residence. No ... (L'sual place of abode) 3 DATE OF December 13 (Month) (Day) DEATH 4 I HEREBY CERTIFY, June - 19 55 to I last saw h. ..... alive on (a) . Coronary Occlusion Due To (b) Arteriosclerosis OTHER SIGNIFICANT CONDITIONS Was autopsy performed? No (Address) Kenmore Hospt DATE OF BURIAL resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, (. I .. ) What test confirmed diagnosis ?. History 7 NAME OF FUNERAL DIRECTOR P R Levine


1956


(Year)


That I attended deceased from


December


-


56


19


Dec 13, 1956, death is said to


have occurred on the date stated above, at


9:15 A. m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


INTERVAL BETWEEN ONSET AND DEATH


yrs


5 Was disease or injury in any way related to occupation of deceased? If so, specify


(Signed) I ... J LoPresti M. D.


Date


12-13


.19 ...


56


6 BINai Brith of Somerville Peabody Place of Burial or Cremation


(City or Town)


Dec .19. 56


ADDRESS. Brookline Mass


Received and filed. 19


PARENTS


50M .11-55.9:6145


R-302 1


M.S.


(Registrar of City or Town where deceased resided)


(Was deceased a


U. S. War Veteran,


if so specify WAR).W.W. T


MEDICAL CERTIFICATE OF DEATH


RECEIVED


OF


TOWA


C


LENK


'11


6 5


THROP


JAN 2 41957 AM


- -


--


--


--


--


--


USCG


- -


--


L


PLACE OF DEATH


(County) / a BOSTON


(City or Town)


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


B


(City or Town making this return) 252


Registered No.


11254


§(If death occurred in a hospital or institution,


St. ( give its NAME instead of street and number)


Samuel Arvedon


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No ..


56 Moore


S


Winthrop,


Mass


(If nonresident, give city or town and State)


Length of stay: In place of death ........... years.


.months.


$2


days. In place of residence.


.. years.


11


.months ..


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX M


9 COLOR


W


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED Married


10a If married, widowed, or divorced


HUSBAND of


Sadie ..... Marget


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


2 days AGE ....


.7.1Years.


Months .......


.. Days


If under 24 hours


Hours .......


Minutes


13 Usual


Occupation :


Employee


(Kind of work done during most of working life)


3 days


14 Industry


or Business :.


Boston Edison Co


2 plus


15 Social Security No ..


--


Boston


16 BIRTHPLACE (City)


(State or country)


Mass


17 NAME OF FATHER Michael Arvedon


PARENTS


18 BIRTHPLACE OF FATHER (City) (State or country) Russia


(Signed) C L Clay M. D.


(Address).


Mass Genl Hospt


Date.


12-14


.19 56


Woburn ...


(City or Town)


Dec


16 1956


21 Informant (Address)


A TRUE COPY/


ATTEST.


(Registrar of City or Town where death occurred)


Received and filed.


TIAC


50M.11.55-916:45


2 FULL NAME (Usual place of abode) 3 DATE OF DEATH (Month) 4 I HEREBY CERTIFY, Dec 12 to I last saw h ........ alive on 19 56 (a) Pulmonary embolism Due To (b) (c) OTHER SIGNIFICANT CONDITIONS Was autopsy performed? No 6 Prideof Boston Cem Place of Burial or Cremation DATE OF BURIAL. 7 NAME OF FUNERAL DIRECTOR 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 resided as soon as possible, after the close of the month in which the death occurred. (Scc Chap. 46, Sec. 12, G. 1 .. ) Due To Hypertensive and


December 14 (Day)


19.56 (Year)


That I attended deceased from


Dec


19 56


Dec


14


19 56 death is said to


have occurred on the date stated above, at


5:25A . m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


INTERVAL BETWEEN ONSET ANO DEATH


Thrombophlebitis of leg


Arteriosclerotic heart disease yrs


What test confirmed diagnosis ?. Clinical


5 Was disease or injury in any way related to occupation of deceased? If so, specify.


19 MAIDEN NAME OF MOTHER Rose Marcus


20 BIRTHPLACE OF MOTHER (City) (State or country) Russia


wife


H Levine


ADDRESS


Brookline Mass


DATE FILED


Dec 20


19 56


-


(Registrar of City or Town where deceased resided)


R-302 1


Mass Genl Hos pt No.


( Was deceased a


L'. S. War Veteran,


if so specify WAR)


L


X


PLACE OF DEATH


(County)


(City or Town)


The Commonwealth of Massachusetts wsè ** ** EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


(City or town making return)


Registered No. 253


J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)


2 FULL NAME. Lu enia Brunoni Faure.)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


..........


St.


Winthrop


(If nonresident, give city or town and State)


Length of stay: In place of death


........... years.


months ... 28.days. In place of residence ...


56years.


.months.


.. days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


Decomber


7/1


1956


(Year)


(Month)


(Day) >


8 SEX


Female


9 COLOR OR RACE


White


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


Widow


4 I HEREBY CERTIFY,


That I attended deceased from


Nov. If


1956


Dec. 11


......


...


56


I last saw h ..... ja .. alive on ......................


3.2 ... 195. death is said to


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


Hoctor .mignani


(Husband's name in full)


DISEASE OR CONDITION


DIRECTLY LEADING


TO DEATH (a)


Uromia ..


INTERVAL BE- TWEEN ONSET AND DEATH 48


11 IF STILLBORN, enter that fact here.


12


AGE 80 Years ..


L Months.


Days


If under 24 hours


Hours.


.. Minutes


ANTE


CAUSES


Due To


... Laennec.I.s ... cirrhosis ....


of liver


Due To


(c)


pi botes ... mellitus


year 5


years


OTHER


SIGNIFICANT


CONDITIONS


Major findings:


Of operations.


Ilone


Date of operation


Was autopsy performed ?.....


.IT.O.


What test confirmed diagnosis ?....


Clinical sions


5 Was disease or injury in any way related to occupation of deceased ?.


If so, specify


(Signed).


James T. Burns


M. D.


(Address)


537


Way,Ve. Date 12/1/ 1955


6


Winthrop Cemetery


Winthrop ....


Place of Burial or Cremation


(City of Town)


DATE OF BURIAL ..


77


196


21


Informant


wand Brugnani


(Address) ), 1-87 1951 40


7 NAME OF


FUNERAL DIRECTOR


ADDRESS.


747


Received and filed


JAN 17 1957


19


(Registrar of City or Town where deceased resided)


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


DATE FILED December 14, 19 56


V.B.


-


PARENTS


17 NAME OF


FATHER


Tu ono Faire


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Franco


19 MAIDEN NAME


OF MOTHER


Cannot be learned


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Ipance


25M (E)-6.50.902253


8.


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 after the close of the month in which the death occurred. (See Chap. 46, Ser 12, G. L.)


1 R-302 1


No. Grover Vanor Hospital


(Was deceased a


U. S. War Veteran,


if so specify WAR)


(a) Residence. No. 105 Cotta e Avenue


(Usual place of abode)


hours


1


13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business:


15 Social Security No.


Mono


16 BIRTHPLACE (City)


(State or country)


I pance


(write the word)


have occurred on the date stated above, at.


7 ... 02.4.m.


RECEIVED


TOWN


JO 701920


MIN


CLERK


5


WII


6


MASS


THROP.


JAN 1 71957 AM


R-302 1


PLACE OF DEATH


(County)


(City or Town)


Mass Cenl Hospt


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION "OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


BOS :-


(City or Town making this return) 254 71239


Registered No.


§(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.)


(a) Residence. No ...


30 Cora


Winthrop


St.


(Usual place of abode)


(If nonresident, give city or town and State)


Length of stay: In place of death ............ years ..


.. months.


10


20


.days.


In place of residence.


years.


months.


... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


December 16


(Month)


(Day)


1956 (Year)


4 | HEREBY CERTIFY,


Dec


6,


19 56,


to.


Dec


Dec


16


1956


I last saw h ........ alive on


4:55A


have occurred on the date stated above, at ... m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


Carcinoma ...


left upper


lobe, Fronchus


INTERVAL BETWEEN ONSET AND DEATH


5 mos


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED.1d owed


10a If married, widowed, or divorced


HUSBAND of.


Annie Mulrennan


(Give maiden name of wife in full)


(or) WIFE of ...


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE


24 Years


Months ...........


.Days


If under 24 hours


Hours ........ Minutes


13 Usual


Occupation :


Retired


(Kind of work done during most of working life)


14 Industry


or Business :.


Fritter, Hospital Appliance


15 Social Security No ...


023-09-1619


16 BIRTHPLACE (City)


(State or country)


Boston


17 NAME OF FATHER Joseph Jenness


PARENTS


(Signed) C L Clay M. D.


(Address)


Vass Genl Hospt


Date


12-16.19 56


St Marys Cem 6


Dorchester


Place of Burial or Cremation


(City or Town)


De c


19


19 56


DATE OF BURIAL


7 NAME OF


FUNERAL DIRECTOR A J O'Maley


Winthrop, Vass


ADDRESS


Received and filed


JAN 28 1951


19


(Registrar of City or Town where deceased resided)


1


50M .: 1.55.916145


Due To (b) 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 Due To (c)


OTHER SIGNIFICANT CONDITIONS


Yes


Was autopsy performed?


What test confirmed diagnosis ?.


Autopsy


18 BIRTHPLACE OF


FATHER (City).


"alden


(State or country)


Fass


19 MAIDEN NAME OF MOTHER Catherine Daley


20 BIRTHPLACE OF MOTHER (City) (State or country) Ireland


21 Irene Jenness


Informant


(Address)


A TRUE COPY charles


ATTEST:


(Registrar of City or Town where death occurred) Dec 21


19 56


DATE FILED


V.B.


No ..


Frederick T Jenness


(Was deceased a


U. S. War Veteran,


if so specify WAR)


That I attended deceased from


16


, 19.56


death is said to


5 Was disease or injury in any way related to occupation of deceased? If so, specify ..


JAN 2'81957 AM


INIA *


i) OF


(1


LERK


HOL


034:3935


×


RHODE ISLAND STATE DEPARTMENT OF HEALTH


COPY OF RECORD OF DEATH


City of Town Clerk's No. ile No.


255


1. PLACE OF DEATH:


(a) County


(b) City or


Town.


Provi dence


(c) Length of


Stay. (in this place)


(c) City or town ....


Winthrop


(d) Full Name of


Hospital or


Institution ...


R I Hospital


(If not in hospital or institution, write street number or location)


3(a) FULL NAME OF DECEASED.


Lucy Barlow


3(b) If veteran,"


3(c) Social Security


name war.


4. Sex.


Female


5. Color or race .....


White


6(a) Single, married, widowed or divorced


Widowed


6(b) If married, widowed or divorced, husband of


(or) wife of.


Charles Barlow


6(c) Age of husband or wife, if aliye.


.years


Feb 25 1872


7(a) Birth date of deceased.


(Month)


(Day)


(Year)


Weeks of


7(b) If STILLBORN enter that fact here.


.gestation


8. AGE:


84


Months


9


Days


24


If less than one day


hr.


........ min.


Rhode Island


10.


Usual occupation


(Kind of work done during most of life,


even if retired)


11 (a) Kind of business or industry


11(b) Date deceased last worked at


this occupation (month and


year)


11(c) Total time (years)


spent in this


occupation ..


FATHER


12.


Name.


13.


Birthplace.


No Kingstown R I


(City, town, or county)


(State or foreign country)


MOTHER


15.


Birthplace ..


Providence


(City, town, or county)


(State or foreign country)


16(a) Informant.


Dorothy S Barlow


(b)


Address.


75 Lorraine Ave


(Street and number)


(City or town)


(c)


Relationship to deceased


Niece


17(a) (b) Date thereof ...


(Month) (Day) (Year)


(Burial, cremation, or remWinthrop Mass


(c) Place : City or town ..


Name of cemetery ..


Winthrop Cem


18(a) Signature of


embalmer.


G Irving Tomey


(License No.)


Funeral Director


(License No.)


Ix(a)


Filed


Dec ... 201956


.19


(Date received by local registrar)


(b)


Local Registrar


٠١٢٧/٢٢٠١١١٨١


I hereby certify that the foregoing is a true copy of the record as recorded in the books of the


Town


of


Providence


Rhode Island


City


DEC ^ : 1956


This copy issued


15:


Date


Local Registrar. CITY REGISTRAR


V. S. 2B 25M 12-54 (over)


* For more space use other side.


X


INTERVAL BETWEEN OHSET AND DEATH


ANTECEDENT CAUSES Morbid conditions, if any, giving rise to the above cause (a) stating the underlying cause last.


Due to. (b)


Due to. (c)


OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not re- lated to the disease or condition causing death.


MAJOR FINOING OF OPERATION


Date ..


. What tests confirmed diagnosis?


AUTOPSY (Yes) (No)


22. If death was due to external causes, fill in the following :


(a) Accident, suicide, or homicide (specify)


(b) Date of occurrence ..


(c) Where did injury occur?


(City or town)


(County)


(State)


(d) Did injury occur in or about home, on farm, in industrial place, in public place ?..


While at work ?.


......


... (Specify type of place)


(e) How did injury occur?


23. Signature.


J M Beardsley M D


(M. D. or other)


Address. .. Date signed ..


....


......................


(b) County.


(d) Street No ....


3 Johnson Terrace


(If rural, give location)


(e) Citizen of what country ?.


MEDICAL CERTIFICATION


20. DATE OF DEATH ..


Dec 19 1956


19


(month, day and year)


21. I hereby certify, that I attended the deceased from


19 ..........


to ..


19


....


that I last saw h ............ alive on ..


19


; death is


said to have occurred on the date stated above at. m


CAUSE OF DEATH (Enter only one cause for [a]. [b] and [c]).


(a) DISEASE OR CONDITION DIRECTLY LEADING TO DEATH This does not mean the mode of dying, such as heart failure, asthenia, etc. It means the disease, injury or complication which caused death. Cancer of Stomach


9.


Birthplace


(City, town, or county)


(State or foreign country)


Years


No.


2. USUAL RESIDENCE OF DECEASED:


(a) State.


Mas.s


Book No. ....... Page.


(b) Name of


Frank E Remington Inc


14.


Maiden Name ..


Lucy B Cole


Nathaniel Greene


Division of Vital Statistics


RECEIVED


OF TOW


OFFICE


11 12


10.


MII


CLERK


ADDITIONAL SPACE FOR FURTHER STATEMENTS BY PHYSICIAN


........... ....... .........


WIN


THROR MAS ...


JAN 2 21957 AM


.....


SPACE FOR VETERANS ADDITIONAL INFORMATION


Date of entering military service .. .


Date of discharge.


Rank, rating.


........


Organization and outfit .. ...........


Service number.


X -


PLACE OF DEATH


Issox


(County)


Danvers


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


Danvers ............


(City or Town making this return)


256


Registered No.


-


Danvers State Hospital, Hathorne No.


§(If death occurred in a hospital or institution, e its


2 FULL NAME Hollie Clark (Marsh)


(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


Winthrop, Mass.


St


(If nonresident, give city or town and State)


Length of stay: In place of death.


... ] ... years ...... 2 ... months ...... Odays. In place of residence ............ years .....


.months.


........... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


December


19,


1956


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


Oct.


9. 19.55.


to Jec.


19.


19.


56


I last saw h ... & live on


Dec.


19 ..... , 19.56, death is said to


have occurred on the date stated above, at


5:15 a.m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


Mesonteric Thrombosis


INTERVAL BETWEEN ONSET AND DEATH


Days


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


Female


White


10 SINGLE


(write the word)


MARRIED


WIDOWED Hidowed


or DIVORCED


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE ofIst name unknown, Clark


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE ..


8.7 Years. 1 ..... Months .... 1.0Days


If under 24 hours


Hours ........ Minutes


13 Usual


Occupation :


Secretary - retired


(Kind of work done during most of working life)


14 Industry or Business:


15 Social Security No.


Unknown


16 BIRTHPLACE (City) ....


.Hardwick


(State or country)


Lass


-


17 NAME OF


Erastus Marsh


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Veruont


19 MAIDEN NAME


OF MOTHER


Sarah Jane Richards


20 BIRTHPLACE OF


Enfield or Greenwich


MOTHER (City)


(State or country)


'ass.


Place of Burial or Cremation (City or Town)


DATE OF BURIAL


December.21


19 56


A. Richmond Walker


ADDRESS Ware, ilass.


Received and filed.


JAN % 151


19


(Registrar of City or Town where deceased resided)


21


Informant.


ary L. Sheehan


(Address)


fathorne, Lass.


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


DATE FILED


Dec.


24,


.. 19.


56


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 Due To (c)


(a) Residence. No ... (Usual place of abode) (Month) (Day) Due To (b) Was autopsy performed? Yes Hardwick 6 7 NAME OF FUNERAL DIRECTOR 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 What test confirmed diagnosis ?. Autopsy


OTHER


Arteriosclerotic Heart


SIGNIFICANT


CONDITIONS


Disease with Coronary occulsion FATHER


5 Was disease or injury in any way related to occupation of deceased? 1f so, specify


(Signed)


Andrew Nichols III


M. D.


(Address)


Hathorne, Mass . Date.


12/19 1 56


Hardwick, Mass.


50M.11.55-916145


M R-302 1


(City or Town)


A R-302 1


X PLACE OF DEATH


SURPOLY (County) BOSTA


(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 this return) 257


Registered No.


77467


§ (If death occurred in a hospital or institution, St. { give its NAME instead of street and number)


Sylvester S Cosman Jr.


(If deceased is a married, widowed or divorced woman, give also maiden name.)


45 Pleasant


"inthrop,


St


(Was deceased a


L'. S. War Veteran,


if so specify WAR)


Fass


(If nonresident, give city or town and State)


Length of stay: In place of death ............ years ...........


.months.


14


hays.


In place of residence


3,5 ars.


months ............ days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


December


19


1956


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


Tec 5


56


19


to


Dec.


19 .. , 19 ..


5€


I last saw h ........ alive on


19.


death is said to


have occurred on the date stated ahove, at


8:55P


„.m.


INTERVAL BETWEEN ONSET AND DEATH


hrs


12


AGE 69


cars


10


Ionths.


18


Days


If under 24 hours


Hours ........ Minutes


13 l'sual


Occupation :


Janitor


(Kind of work done during most of working life)


14 Industry


or Business:


Puilding


15 Social Security No.


028-07-9817


16 BIRTHPLACE (City)


(State or country)


Fass


17 NAME OF


FATHER


Sylvester S Cosman


PARENTS


18 BIRTHPLACE OF


FATHER (City).


(State or country)


Nova Scotia


19 MAIDEN NAME


OF MOTHER


Alice Ford


20 BIRTHPLACE OF


MOTHER (City).


(State or country)


Hospital Records


DATE OF BURIAL


7 NAME OF


F S Reynolds


FUNERAL DIRECTOR


ADDRESS. Winthrop, Wass


Received and filed .. FE8 5 195,


19


(Registrar of City or Town where deceased resided)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED


Widowed


10a If married, widowed,


HUSBAND of.


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


DEATH


(Month)


(1)


Duequodenal ulcer


(c)


Was autopsy performed?


Yes


(Signed)


P L Sallade


(Address)


VAH Poston


6


WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD


(a)


?Cardiac arrythmia


Due To


Sub hepatic abscess


secondary to perforated


days


5 Was disease or injury in any way related to occupation of deceased? If so, specify


M. D.


Date


12-20


.19 ...


56


inthrop Cem Place of Burial or Cremation


Winthrop


(City or Town)


Dec 221, 5


21


Informant.


(Address)


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


DATE FILED


Dec


26


19


56


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 CONDITIONS


50M.11.55-916145


No.


Vet Adm Hos pt


2 FULL NAME.


(a) Residence. No. (Usual place of abode)


I


Campbell


11 IF STII.LBORN, enter that fact here.


Revere


What test confirmed diagnosis ?.


Autopsy


OF TOWA


WIN


6 5


FEB =; 51957 AM


5-28-1º 7-15-19 Cpl TIS Army 385263


4


› not write in his space - Mar- in reserved for CODING and BINDING.


DATE OF DEATH 20-25-56


PLACE OF DEATH 7-08


INSTITUTION 's


RESIDENCE X 2


SEX 2


sc


AGE


99


+


1


CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE


258


STATE FILE NO.


1. NAME OF


DECEASED


A. (FIRST)


.. (MIOOLE)


C. /LAST)


2. DATE


(MONTH)


(DAY)


TYEARI


OF


DEATH December 25, 1956


(TYPE OR PRINT)


Mary


E.


Hall


3. PLACE OF DEATH


A. COUNTY


Merrimack


4. USUAL RESIDENCE INNERE OECEASEO LIVED. IF INSTITUTION RESIDENCE


A. STATE


Massachusetts


$. COUNTY


BEFORE ADMISSION.)


C. LENGTH OF


STAY IIN THIS PLACE}


C. CITY (GIVE ACTUAL YOWN OF RESIDENCE, NOT NAILING AODRESS).


OR


TOWN


Winthrop


B. CITY


OR


TOWN


Concord


7 yrs. 10 mos. 1 day


D. FULL NAME OF (IF NOT IN HOSPITAL OR INSTITUTION, GIVE STREET ADORESS OR LOCATION!


HOSPITAL OR


INSTITUTION


D STREET IIF RURAL, GIVE LOCATION)


ADDRESS


125 Cliff Ave,


YES


NO


5. SEX


6. COLOR OR RACE 7.


Female


White


MARRIED NEVER MARRIED


DIVORCED


WIDOWERKIT


9. DATE OF BIRTH


Aug. 11, 1857


10. AGE IIR YEARS


LAST BIRTH


99


IF UNOER 1 YEAR MONTHS DATS


IF UNDER 24 HRS HOURS MIN.


11A. USUAL OCCUPATION (KINO OF WORK DOWE DURING MOST OF WORKING LIFE. EVEN IF RETIRED)


11B. KIND OF BUSINESS OR INDUSTRY Retired Christian Science Practitioner


12. BIRTHPLACE ICITY OR TOWN, STATE


Scotland, Came" to""nhode


13. CITIZEN OF WHAT


COUNTRY?


USA


14. FATHER'S NAME George Henry Watts


15. MOTHER SodidHen A baby


Isabelle Snedden


16. WAS DECEASED EVER IN U.S. ARMED FORCES? 17. SOC. SEC. NO. IYES, NO. OR UNKNOWN) [{IF YES. GIVE WAR OR DATES DE SERVICE) no -


none


18A INFORMANT


Helen A. Sawyer


188. ADDRESS


19. CAUSE OF DEATH (ENTER ONLY ONE CAUSE PER LINE FOR (A). (B), AND ICI


PART I DEATH WAS CAUSED SY,


Chronic Myocarditis


INTERVAL BETWEEN ONSET AND DEATH B mos,


CONDITIONS. IF ANT. WHICH GAVE RISE TO ABOVE CAUSE TAI. STATING THE UNOER. LYING CAUSE LAST.


DUE TO (BI


Senility


?


PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART IIA)


20. WAS AUTOPSY


PERFORMED!


YES


NO


21A. ACCIDENT SUICIDE HOMICIDE


218. DESCRIBE HOW INJURY OCCURRED IENTER NATURE OF INJURY IN FART | OR PART TI OF ITEM 18.1


CITIZENSHIP 1


VETERAN 2.


AUSE OF DEATH 1222


DIAGNOSIS


CREMATION


246. DATE


12-27-56


24 C. NAME OF CEMETERY OR


CREMATORY


Mount Auburn Cem.


240. 10


Cambridge, Mass.


IF ENTOMBED


24E. PLACE OF BURIAL


NAME OF CEMETERY)


LOCATION .CITY, TOWN. COUNTT)


ISTATEI


DATE


25. FUNERAL DIRECTOR'S SIGNATURE


Peaslee & Maxham


Concord, N.H.


ADDRESS


COUNTERSIGNED . AGENT (CITT BO. OF HEALTH)


P. A. Boucher, M. D.


DATE


12-26-56


DATE REC'D BY TOWN OR CITY CLERK


Dec. 26, 1956


CLERK'S OWN SIGNATURE


Afthur E. Roby


CLERK OF


Concord, I !. H,


Clerk of


Concord, I .H.


Dated.


Dec. 27


56 15.


X


5 tedy true copy, Allest: ..


21E. PLACE OF INJURY IE. G., IN OR ABOUT NOME, FARM. FACTORT, STREET. OFFICE BLOG., ETC.


21F CITY, TOWN OR LOCATION COUNTY


STATE


22. I attended the deceased from


never seen alive-Christian Scientister


alive on


Death occured at


8:45 a.


in on the date stated above: and to the best of my knowledge, from the causes stated.


23A. SIGNATURE


Robert 0. Blood


IDEGREE OR TITLEI


D


23B. ADDRESS


23C. DATE SIGNEO 920656


M


N


24A. BURIAL


ENTOMSMENT


REMOVAL


NOT WHILE


MEDICAL CERTIFICATION


21C. TIME


OF


INJURY


MONTH


DAT


YEAR


HOUM


M.


21D. INJURY OCCURRED


WHILE AT


WORK


AT WORK


IMMEDIATE CAUSE (A)


OCCUPATION


BIRTHPLACE 19


DUE TO (C)


NAME OF HUSBAND OR WIFE INAIOEN MANE IF WIFE)


E. 15 RESIDENCE


ON FARMP


Christian Science Pleasant


View Home


TOWN OR CITY CLERK'S NO ..


RECEIVED


OF


VMOL


OFFI


NILS


CLERK


and


5


6


ASS.


FEB


. . 51957 AM


..


-


45


சதி


444+


...


-


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----


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14年年の中


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