USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1957 > Part 42
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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, 8ec. 16 GL .L., (Tercentenary Edition). .
.
RULES OF PRACTICE ..
The fulfillment of the purpose of theselaws calls for the observance of the follow- ing rules of practice:
(1) Attending physicians willcertify 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 Hijury.
(2) Board of Health, physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners, will investigate and certify to all deaths supposably due to injury. These-include"not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from use seretoting from injury or infection related to occupation, the sudden death of persons hot 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
X
PLACE OF DEATH
- Suffolk ( ((County) Winthrop (City or Town)
Chelsea 6-28-57
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No.
123
S(If death occurred in a hospital or institution,,
Mounts Convalescent Nome, Ine_
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
100
if so specify WAR)
Chilvia S
(Usual place of abode)
(If nonresident, give city or town and State)
50 ears“ months ............ days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
June
27
1957
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
19
That I attended deceased from
19:
Jan
52
June
27
I last saw himalive on
June
26, 1957
death is said to
have occurred on the date stated above, at ... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cerebral hemorrhage
(a)
Due To
Cardio-renal disease
(b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
No
Clinical Signs
What test confirmed diagnosis ?...
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify ...
(Signed)
M. D.
(Address)
Date
Chevra Jarah Tiverent
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL. June 18.
7 NAME OF
FUNERAL DIRECTORS
Darf Funeral Server Sun
ADDRESS
Received and filed.
JUN 28 1957
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
10a If married, widowed, or divorced
HUSBAND of
Malar
Dolink
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
40 years
MonthsDays
If under 24 hours
Hours .......
.Minutes
13 Usual
Diale-
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
Waste materials
15 Social Security No.
none
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Philip Peretz
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
( B.Z.)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21 Informant
Andre
Sifrances (1 tix exp.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed With me BEFORE the burial or transit permit was issued: Malku C .- fireanul ( Signature of Agent of Board of Health of Other)
6/28/97
(Official Designation )
(Date of Issue of Permit)
X
1
to ..
13up
INTERVAL BETWEEN ONSET AND DEATH 2 dys
6 yrs
100M.11.55.916145
-
2 FULL NAME
(If deceased is a married, widowed or Hvorced woman, give also maiden name.)
(a) Residence. No .. 12 auk
Length of stay: In place of death
5 years - months ...
days. In place of residence!
To be filed for burial permit with Board of Health or its Agent.
R-301A 1
CTIONS OR CERTIFICATE iving F DEATH t enter han one for each ) and (c)
es not mcan of dying, art failure, c. It means „or compli- ich caused
s, if any, ve rise to usc (a), he under- use last.
ons contrib. cath but not the terminal dition given
Chapter 137, $54, requires s to print or cause or { death on tificates.
PARENTS
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 hy 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 de 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 of burial ground in which the interment is made.
bap. 114/ Seca 46, G. L., (Tercentenary Edition).
11 12 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 whopt 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 persous who, though disabled by recognized disease unrelated to any form of injury have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation. the sudden deaths 'of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very import- ant, so that the relative healthfulness of various pursuits 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
........
1 R-302 1
PLACE OF DEATH
Essex
(County)
Danvers
(City or Town)
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)
121
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME. FLOYD, Mary E. (Mary E. Wells)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No .. 114 Winthrop Street, Winthrop, Mass.
Length of stay: In place of death.
.years ..
10
months.
28
.days. In place of residence.
........... years.
.. months.
......... days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED Jidowed
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
Archie C. Floyd
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
Years 83
12
AGE
Years.
5
Months
12 Days
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry or Business :
15 Social Security No ..
Unknown
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
Arthur Wells
PARENTS
18 BIRTHPLACE OF
Unknown
FATHER (City) (State or country) Mass.
19 MAIDEN NAME
OF MOTHER
Emma Pease
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Unknown
Mass.
21 Informant
Mary E. Sheehan
(Address)
Hathorne, Mass.
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
June 12,
19 .. 5.7
X
(Usual place of abode) 8 3 DATE OF DEATH (Month) (Day) (a) Myelogenous Leukemia OTHER Generalized SIGNIFICANT Was autopsy performed ?. Yes What test confirmed diagnosis ? Autopsy resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, (. 1 .. ) CONDITIONS Arteriosclerosis
25M-8-58-918227
Due To (c) 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 (b)
MEDICAL CERTIFICATE OF DEATH
June
3
1957
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
April 10
50
19.
to
June 3,
57
19.
I last saw h ellive on June 3
19.5.7, death is said to
have occurred on the date stated above, at
3:00 p. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH
Years
5 Was disease or injury in any way related to occupation of deceased ?. If so, specify
(Signed) Andrew Nichols IIF M. D. (Address Hathorne, Mass. Date 6/3/57 19
winthrop Cemetery, winthrop, Mass 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL. June 5, 19.5.7
7 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS
"inthrop, Mass
Received and filed JUL 17-1957 19
(Registrar of City or Town where deceased resided)
No.
Danvers State Hospital
Registered No.
i
(Was deceased a
U. S. War Veteran,
if so specify WAR)
No
(If nonresident, give city or town and State)
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
Springfield
, 1 1? ;
JUL 1 71957
write in
a reserved CODING BINDING.
BIRTH NO
128-
(De not write in this Space)
TE OF DEATH 123,5"
CE OF DEATH 6-18
ISTITUTION 9
RESIDENCE
×20
SEX
1
S
ATE OF BIRTH
AGE
53
OCCUPATION
"IRTHPLACE
20
CITIZENSHIP 1
VETERAN
2
24& BURIAL. CREMATION.
24b. DATE
ENTOMBMENT, REMOVAL
burial
June 27-57
24c. NAME OF CEMETERY OR CREMATORY
Winthrop Cem,
24d. LOCATION (City, town, or county ) (State)
Winthrop, Mass.
IF ENTOMBED
24%. PLACE OF BURIAL
( Name of Cemetery )
LOCATION (City, Town, County ) ( State)
DATE
ADDRESS
COUNTERSIGNED · AGENT (Cky Bd. of Health)
DATE
DATE REC'D BY TOWN OR CITY CLERK
June , 24,1957
CLERK'S OWN SIGNATURE
L. Evelyn Bake
CLERK OF Kingston
A true copy, Attest:
L. Evelyn Babe
c. (Lest)
(Month)
(Day)
(Your)
(Type or Print)
James
Powers
2. DATE
OF
DEATH June
23,1957
3. PLACE OF DEATH
a. COUNTY
Rockingham
4. USUAL RESIDENCE (Where deceased lived. If institution: rouid-
ence before admission).
a STATE
b. COUNTY
Suffolk
b. CITY
OR
TOWN
Kingston
c. LENGTH OF
STAY (in thịt place)
5hrs
e. CITY (Give actual town of residence, NOT mailing address).
OR
TOWN
Winthrop
d. FULL NAME OF (If not in hospital or institution, give street address or location)
HOSPITAL OR
INSTITUTIONNEW Hampshire State Park
d. STREET
ADDRESS
249 Shore Drive
9, AGE (In years| IF UNDER I VEAM Months! Days last birthday)
IFUNDER LE HAS
Hours
Min.
5. SEX
vale
h
6. COLOR OR RACE |7. MARRIED, NEVER MARRIED ..
WIDOWED,DIVORCED (Specify)
Married
Dec. 11,1908
53
12. CITIZEN OF WHAT
COUNTRY?
Book-keeper
IstNational Bank
Jamaicaplain.
.S
13. FATHER'S NAME
Joseph P. Powers
14. MOTHER'S MAIDEN NAME
Georgia Miller
MEDICAL CERTIFICATION
INTERVAL BETWEEN
ONSET AND DEATH
11. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related to the disease or condition causing it.
19a. DATE OF OPERA- 19b. MAJOR FINDINGS OF OPERATION TION
21 .. ACCIDENT
SUICIDE
HOMICIDE
(Specify)
21b. PLACE OF INJURY (e.g., In or sbout
home, farm, factory, street, office bidg., etc.)
21c. (CITY OR TOWN)
(COUNTY)
(STATE)
21d. TIME
OF
INJURY
m
Month) (Day) (Year) | Hour)
21e. INJURY OCCURRED
WHILE AT
NOT WHILE
WORK
AT WORK
21f. HOW DID INJURY OCCUR?
22. I hereby certify that I attended the deceased fromisver
alive on
Never
, 19
, and that death occurred at 5 .. 30. . p., from the causes and on the date stated above.
23e. SIGNATURE
W.P.Clare MED. Referee
( Degree or title)
123b. ADDRESS
Portsmouth ,N.H.
23c. DATE SIGNED
June23-57
AUSE OF DEATH 1200
DIAGNOSIS
CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE
TOWN OR CITY
172 125
CLERK'S NO
STATE FILE NO
1. NAME OF
L (First)
DECEASED
b. (Middle)
martin
8. DATE OF BIRTH
10a. USUAL OCCUPATION (Kind of work 10b. KIND OF BUSINESS OR IN- 11. BIRTHPLACE (State or foreign country)
done during most of working life, even if retired)
DUSTRY
16. SOCIAL SECURITY 17. INFORMANT
15 WAS DECEASED EVER IN U. S. ARMED FORCES?
unknown) | (If yes, give war or dates of service)
020-14-4350
18. 1. DISEASE OR CONDITION DIRECTLY LEADING TO DEATH This does not mean the mods of dying, such as heart failure, DUE TO asthenia, etc. It means the disease, injury, w complication which caused death. (٩)
Coronary occlusion
TO
Arterioscleretic cardiac.
DUE TO
ANTECEDENT CAUSES
Morbid con.
titions, if any, giving rue to the above cause
(a) stating the underlying cause last.
(c)
Arteriosclerosis general
20. AUTOPSY?
, 19 .
, to Ne ver
, 19
that I last saw the deceased
25. FUNERAL DIRECTOR
Alfred B. March 174Winthrop St Winthrop, Mass
Clerk of
Kingston
C
Dated June 2619 57
JUL 29 1957
(If rural, give location)
RECEIVED
TOW.
1 12 1
ALLERK
C
JUL 2 91957 AM
X
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
Boston
(City or Town making this return)
59640 128
Osteopathic Hospt So. Huntington AVA 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.)
( Was deceased a
U. S. War Veteran,
(a) Residence.
No .-
(Usual place of abode)
89 Circuit Road
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
June 24/57
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
June 24
57
Oct.
19
54.
to
I last saw h.elalive on
June 24 1957, death is said to
have occurred on the date stated above, at
11; 35A
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute coronary occlusion
(b) Due To Coronary heart disease
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ?.
No
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?..... O. If so, specify.
(Signed)
S K Partridge
M. D.
(Address)
Malden Mass.
Date.
6-24 19 57
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
June 27/57
19
7 NAME OF
FUNERAL DIRECTOR
H S Reynolds
ADDRESS Winthrop Mass.
Received and filed ..
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
F
9 COLOR
W
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
10a If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
Alpine F McLean
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12 Hrs 12
AGE.7.2 Years
7 Mont
26
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
Own Home
15 Social Security No ..
None
16 BIRTHPLACE (City).
Revere Mass ..
(State or country)
17 NAME OF
FATHER
Herbert West
18 BIRTHPLACE OF
FATHER (City).
(State or country)
---
19 MAIDEN NAME
OF MOTHER
Anna Bradley
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Hazel McClean Chase
21
Informant.
(Address)
A TRUE COPY
E COPY Les H. Mackie
ATTEST:
(Registrar of City or Town where death occurred)
June
28/57
DATE FILED
19 ..
X
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 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, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, (i. I .. )
1 2-302 1
THIS IS A PERMANENT RECORD
WRITE PLAINLY, WITH UNFADING BLACK INK
10 Yrs
PARENTS
Glenwood Cem-Everett Mass .
25M-8-56-918227
No.
Laura Mclean
Registered No.
if so specify WAR)
19
INTERVAL BETWEEN ONSET AND DEATH
RECEIVER
TOWA
OF
11.12
11).
..
G
RK
-
5
JUL 121957 74
-
PLACE OF DEATH
Suffolk (County)
VERE
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
122
No.
2 FULL NAME
Frederick E Cotter
(If deceased is a married, widowed or divorced woman, give also maiden name.).
125 Endicott ave Reverra.
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death .years_ months / days. In place of residence.
(If nonresident, give city or town and State)
4
years.
2 months.
days.
.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July
3
1957
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
19 57 to
1957
IQast saw hissalive on
, 195, death is said to
have occurred on the date stated above, at 10.300 m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cleute Pulmonary Edena
(b)
Due To
Ventricular Heart Fail
Due To (c)
Chronic Myocarditis
5 yrs
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis
Olivalex on-4 History
5 Was disease or injury in any way related to occupation of deceased? and If so, specify ..
(Signed) ...
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