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