USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1957 > Part 37
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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 any form of injury.
(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 fecent medical attendance or whose physician is absent from home when the certiddate 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
......
M R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
2 FULL NAME (a) Residence. No. 3 DATE OF DEATH (Month) Due To (1)) Due To (c) OTHER SIGNIFICANT CONDITIONS Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Was autopsy performed ?.... Y.es What test confirmed diagnosis? 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
25M-8-58-918227
PLACE OF DEATH
Suffolk
(County)
Boston
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Bostan
(City or Town making this return)
109
5201
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
Baby Girl Jacques
(If deceased is a married, widowed or divorced woman, give also maiden name.)
40 Tewksbury
St.
Winthrop Mass .
(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.
6 hrs
15 mins.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
F
9 COLOR
W
10 SINGLE
MARRIED
WIDOWED
Single
or DIVORCED
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 ...
Years.
.Months ..
Days
If under 24 hours
10 ... Hours ........ Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No.
16 BIRTHPLACE (City) ..
(State or country)
17 NAME OF
FATHER
William E Jacques
18 BIRTHPLACE OF
Bogto Mass
FATHER (City).
(State or country)
19 MAIDEN NAME
OF MOTHER
Christine A Sepe
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Morristown N.J.
Winthrop Cem-Winthrop Wass.
6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL.
May 31/57
19
7 NAME OF
FUNERAL DIRECTOR
M Kirby
Winthrop Mass.
ADDRESS
Received and filed. JUN 21 1957 19
21
Informant
(Address)
William E .... Jacques
A TRUE COPY
Parles At Mackie.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
June 7/57
19
(Registrar of City or Town where deceased resided)
May.29 /57
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
May ... 29, 19 57 to May 29
19.
57
I last saw h .. e.Plive on
May
29., 19 ........ 5,7death is said to
have occurred on the date stated ahove, at
11 .; 30A
.. m.
INTERVAL BETWEEN ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Hemolytic disease of newborn
DEATH
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed) Robert .... Usher M. D.
(Address)
300 Longwood Avere
.5-2919 ..... 5.7
PARENTS
No.
Children's Hospt.
Registered No.
(Was deceased a
U. S. War Veteran,
if so, specify WAR)
(write the word)
MEDICAL CERTIFICATE OF DEATH
Winthrop Mass.
€
R-301A 1
PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burlal permit with Board of Health or its Agent.
Registered No. 110
((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)
(a)
Residence. No ..
97 Johnson Ave.
... St
(Usual place of abode)
30
Length of stay: In place of death
.. years.
.months.
days. In place of residence 50
.years.
months.
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June
1
1957
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
June
19,6521
to
June 1
195%
I last saw h elaTive on
Tiene 1, 192/, death is said to
have occurred on the date stated above, at
9 50-P1 m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Broncho pneumonia
(termind)
Due To
Cerebrovascular
(b)
accident
Due To
(c)
arteriosclerosis
generalized
OTHER
SIGNIFICANT
CONDITIONS
Diabetes Mellitus
Was autopsy performed? What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed) peple beyond M. D. res) 197Washington15 Date 1-8-1957
6 Woodlawn
Everett
Place of Burial or Cremation (City or Town) June
4 1957
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
lumeny mar
ADDRESS
Received and filed JUN 4 1937 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
White
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDWidow
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE
Sydney Packard
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12 82
O
AGE
Years
Months ...
8
.Days®
Hours ........ Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Own home
15 Social Security No ..
None
Chelsea
16 BIRTHPLACE (City).
(State or country)
lass .
17 NAME OF
FATHER
Stephine A Bayley
18 BIRTHPLACE OF
FATHER (City)
Amesbury
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Caroline Wadsworth
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass
21
Informant.
Barbara P.Emerson
(Address) 99 Johnso Ave Winthrop
| HEREBY CERTIFY that a satisfactory standard certificate of death was fred with me BEFORE the burial or transy permit was issued:
habkuru.
(Signature of Agent of Board of Health or other)
Relative ceviz
0/4/57
(Official Designation)
(Date of Issue of Pernity
UCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each b) and (c)
oes not mean : of dying, heart failure, tc. It means e, or compli- which caused
ns, if any, ave rise to cause (a). the under- cause last.
tions contrib- dcath but not the terminal ndition given
Chapter 137, 1954, requires ns to print or e cause or of death on rtincates.
100M. 11.85-916148
INTERVAL BETWEEN ONSET AND DEATH
1day
7days
grs
PARENTS
Chelsea
No.
97 Johnson Ave .
2 FULL NAME
Alice W ( Bayley) Packard
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(If nonresident, give city or town and State)
If under 24 hours
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).
a
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, er 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, 6t 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 any form of injury.
(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 Examinerbwill 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
...
R-301A 1
PLACE OF DEATH
Suffolk (County) Winthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No. 111
No .. Winthrop Community Hospital
f(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)
NO.
(a) Residence. No.
30 Siren
(Usual place of abode)
St. (If nonresident, give city or town and State)
CTIONS OR CERTIFICATE Length of stay: In place of death .years months. 5 days. In place of residence. 26 years. .. months ..... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June 3,
1957
(Month)
(Day)
(Year)
male
9 COLOR
white
10 SINGLE
(write the word)
married
MARRIED
WIDOWED
or DIVORCED
4 I HEREBY CERTIFY,
That I attended deceased from
Jan. 5,, 1953, to June 3
57
I last saw hill alive on
June 3,
1957., death is said to
have occurred on the date stated above, at
1:45 PM.
10a If married, widowed, or divorced
HUSBAND of
Ella Josephine Tinning
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
If under 24 hours
Hours
Minutes
13 Usual
Occupation :
Ontition
(Kind of work done' during most of working life)
6 mos
44 Industry
or Business:
Commercial Optical Co.
15 Social Security No.O11-10-2704-A.
Worcester
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
Danial Webster Dorman
18 BIRTHPLACE OF
FATHER (City)
Worcester
(State or country)
Masa.
19 MAIDEN NAME
OF MOTHER
Hattie Pendleton
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Maine
21
Informant
Mrs. LeRoy A: Dorman
(Address)
30 Siren St .Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit. was issued :
Mass.
(Signature of Agent of Board of Ilcalth or other)
Kravile face
(Official Designation) (Date of Issue of l'ermn) 6/4/57
- (b)
Ascites
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Berger's Disease
Diabetes mellitus
3 yrs 8 yrs .
Was autopsy performed ?..
no
What test confirmed diagnosis? Clinical & Laboratory
5 Was disease or injury in any way related to occupation of deceased ? no If so, specify
(Signed)
myso n. Rug
M. D.
(Address)
Winthro
222 Pleasant Straat, 6/3/57
6Winthrop Cemetery. Winthrop,Mass, Place of Burial or Cremation (City of Town)
DATE OF BURIAL June-6/1957 19
7 NAME OF
FUNERAL DIRECTOR
Crefied BB. March
ADDRESS
174 Winthron-St. Winthron.
Received and filed
JUN 5 1957
19
(Registrar)
PARENTS
INTERVAL
BETWEEN
ONSET AND
2AYrs
2 mos AGE 2 Years
2
+2
Months 2.
Days
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Arteriosclerotic heart &
Nephrosclerosis with Azotemia
Due To
Cirrhosis of liver with
iving F DEATH t enter han one for each ) and (c)
es not mean of dying, eart failure, c. It means or compli- hich caused
s. if any, ve rise to ause (a), the under- ause last.
ons contrib- - ath but not the terminal dition given
Chapter 137, 54, requires s to print or cause or death on idcates.
To be filed for burial permit with Board of Health or its Agent.
2 FULL NAME LeRoy Arthur Dorman
(If deceased is a married, widowed or divorced woman, give also maiden name.)
8 SEX
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- 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, 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.
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