USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1957 > Part 48
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years
months
days. In place of residenceyears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
28
(Day)
1957
(Year)
4 I HEREBY CERTIFY,
1/1
056
to ...
7/28
1957
I last saw halive on
7/28
, 195, death is said to
have occurred on the date stated above, at
8.45 m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
BRONCHI-PNEUMONIA
(a)
Due To
ARTERIO-SCLEROTIC
(b)
HEART DISEASE
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
150
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? 119 If so. specify
(Signed).
FRED C' BEGAN
, M. D.
(Address) 13 PLEASANT STWelches 7/20 1957
6 Pinage are. Com.
Cambridge
Place of Barial or Cremation DATE OF BURIAL
august 9
19.
5-
7 NAME OF
FUNERAL DIRECTOR
Charles D. Keep 6
ADDRESS 275 Mass are. Canal.
Received and filed. HJUL 30 1957 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR.
Stenale White
10 SINGLE
(white the word)
MARRIED ,
WIDOWED
or DVORerbacced
10a If married, widowed, or divorced
HUSBAND of
Peter
(or) WIFE of
ZGive maiden name of wife in fullb
Bedand
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
88.
.Years.
11
Months 13 Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No ...
nane
16 BIRTHPLACE (City) New Brunswick
(State or country)
17 NAME OF
FATHER
Landry
18 BIRTHPLACE OF FATHER (City) (State or country) Canada
19 MAIDEN NAME OF MOTHER
Cannot be learned
20 BIRTHPLACE OF
Luncada
MOTHER (City)
(State or country)
Mrs. OF lawel Skaw
21
Informant
(Address) 2552 Mais ant Canik
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued :
(Signature of Agent of Board of Health or other)
Chepita Officer (Official Designation) (Date of Issue of Permit)
7/30 57 X
₹.01A 1
DONS R
EUFICATE
DEATH ter one each nđ (c)
ot mean dying, failure, t means compli- caused
f any, :rise to (a). · under- 1 last.
I contrib- but not terminal on given
.pter 137, requires › print or :ause or leath on :ates.
SOM-11-56-918978
1400
Registered No.
[(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).
(Usual place of abode)
2
That I attended deceased from
INTERVAL
BETWEEN
ONSET AND
DEATH
3 DAYS
5 yes
PARENTS
(City or Town)
2 FULL NAME
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 (Icath 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 belicf 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, ninetcen 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., (Tereentenary 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 for 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 derk 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 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
VS-R3 1-1-56 X
OF MAINE SMENT OF HEALTH AND WELFARE
CERTIFICATE OF DEATH
STATE FILE NO.
141
1. PLACE OF DEATH
a. COUNTY
Oxford
2. USUAL RESIDENCE Where deceased lived. If institution: residence before admission
a. STATE
Mass.
b. COUNTY
b. CITY, TOWN, OR LOCATION
Fryeburg
c. LENGTH OF STAY IN 1b
1 week
c. CITY, TOWN, OR LOCATION
Winthrop
d. NAME OF
HOSPITAL OR
INSTITUTION
(If not in hospital, give street address)
d. STREET ADDRESS
158 Hermon St.
e. IS PLACE OF DEATH IN RURAL AREA?
YES Mİ
NO
e. IS RESIDENCE IN RURAL AREA?
YES
NO Q
X
f. IS RESIDENCE ON A FARM?
NO
YES
3a. NAME OF DECEASED - First Name
Ingeborg
| 3b. Middle Name
Petersen
| 3c. Last Name
-
Petersen
4. DATE
OF
DEATH
July 28
1957
Female
10a USUAL OCCUPATION (Give kind of work
done during most of working life, even if retired)
Housewife
10b. KIND OF BUSINESS OR
INDUSTRY
11. BIRTHPLACE (State or foreign country)
Copenhagen, Denmark
12. CITIZEN OF
WHAT COUNTRY?
U. S.
13. FATHER'S NAME
Anker Petersen
14. MOTHER'S MAIDEN NAME
Unknown
15. NAME OF SPOUSE (If Married)
Ludwig Petersen
16. WAS DECEASED EVER IN U.S. ARMED FORCES?
(Yes, no, or unknown) (If yes, give war or dates of service)|
IVO
18. INFORMANT
Address
Robert Petersen, E, Hamilton, Mass.
19. CAUSE OF DEATH (Enter only one cause per line fo (a), (b), and (c).)
PART 1. DEATH WAS CAUSED BY:
IMMEDIATE CAUSE (a)
Coronary thrombosis, acute
INTERVAL BETWEEN
ONSET AND DEATH
Immediate
Conditions, if any, which gave rise to above cause (a) stating the under- lying cause last. DUE TO (c).
PART II. Other significant conditions contributing to death but not related to the terminal disease condition given in Part I(a)
20. WAS AUTOPSY
PERFORMED?
YESO NO 0
21a. ACCIDENT
SUICIDE
HOMICIDE
ATH E TO ERNAL ENCE
21c. TIME OF
INJURY
Hour
a.m.
p.m.
Month, Day, Year
21d. INJURY OCCURRED
WHILE AT
WORK
NOT WHILE
AT WORK
21e. PLACE OF INJURY (e.g., in or about home, farm, factory, street, office bidg., etc.)
21f. CITY, TOWN, OR LOCATION
COUNTY
STATE
SICIAN'S MEDICAL
7-1957
22a. MEDICAL EXAMINER: I hereby certify that death occurred at the time and from the causes stated above, and that I held an (investigation) (autopsy) on the re- mains of the deceased as required by law.
22b. to at
PHYSICIAN: I hereby certify that I attended the deceased from
DOA
and last saw him alive on
Death occurred
12:45 A
m on the date and from the causes stated above,
23a. SIGNATURE
(Degree or title) Kenneth E. Dore, M. D., Med. Exam.
23b. ADDRESS
133 Main St., Fryeburg, Me.
23c. DATE SIGNED
7/28/57
VERAL ECTOR AND
ISTRAR
24a.
BURIAL, CREMATION,
REMOVAL (Specify)
Burial
24b. DATE
7/31/57
24c. NAME OF CEMETERY OR CREMATORY
Winthrop
25. FUNERAL DIRECTOR
F. A. Hill
ADDRESS Son, Fryebur
26. DATE RECD. BY LOCAL REG. 8/1/57
OZ REGISTRAR'S SIGNATURE- A TRUE COPY ATTEST: Just in. Pagen Deputy Cluck
DENT ONAL TA
E OR NAME
5. SEX
6. COLOR OR RACE
White
7. Married [
Never Married
Widowed
8. DATE OF BIRTH
Divorced
9. AGE (In years
last birthday)
67
If under 1year Mos 7
Days 28
Hrs
Min.
5/30/1890
Month
Dạy
Year
if under 24 hrs
USE OF JATH
IE TYPE PRINT
21b. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury In Part I or Part II of item 18).
MINER'S FICATION
24d. LOCATION (City, town, or county)
inthrop, Lass.
(State)
VBL
LE OF H AND JAL DENCE
DUE TO (b)
17. SOCIAL SECURITY NO.
AUG -- / 1357 45
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 burial permit with Board of Health or its Agent.
142
No. Mayflower Nursing Home
[(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.
35 Amelia
Avenue
(Usual place of abode)
St
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death
years
4를
days. In place of residence3.
years.
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
4 I HEREBY CERTIFY,
That I attended deceased from
December 18, 1953 ., to.
July31
19.5.7
I last saw leralive on
July 30 ,-19.57 , death is said to
have occurred on the date stated above, at
2:25 am.
INTERVAL BETWEEN ONSET AND DEATH
5 days
Due To
(b)
Hypertension
7 yrs.
Due To
(c)
Arteriosclerosis
7 yrs.
7 yrs.
Was autopsy performed?
No
What test confirmed diagnosis ?.
Physical Examination
5 Was disease or injury in any way related to occupation of deceased ? No If so, speciff ).
(Signed)
(Address) 27 Bennington St
Date .... August 19.57
6 Woodlawn Everett
Place of Burial or Cremation
(City or Town)
DATE OF BURIALAugust 2, 1957
19
7 NAME OF FUNERAL DIRECTOR Arthur S. Porcella ADDRESS 876 Winthrop Ave., Revere, Yass
Received and filed
19
(Registrar)
PARENTS
17 NAME OF
FATHER
James Fredericks
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Canada
19 MAIDEN NAME
OF MOTHER
Priscella Johnson
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
21
Informant
William B. McKeen
(Address) 35 Amelia Ave. ,Winthrop, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued :
(Signature of Agent of Board of Health or other)
(Official Designation)
V . (Date of Issue of Permit)
8/2/57 X
JC ONS
CE IFICATE
ng DEATH ater one each ind (c)
not mean dying, failure, It means compli- caused
if any, rise to (a), under- last.
contrib- h but not terminal ion given
apter 137, , requires to print or cause or death on
icates.
SOM-11-56-918978
3 DATE OF
DEATH
July.
31
1957
(Year)
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .... Brainard E. McKeen
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 59 Years 9
Months.
Days 30
If under 24 hours
_Hours .....
Minutes
13 Usual
Occupation :
At home
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No ...
none
16 BIRTHPLACE (City) (State or country) Mass
Revere
OTHER
SIGNIFICANT
Hemiplegia from previous
CONDITIONS
Cerebral Hemorrhage
, M. D.
Rovere SI Hass.
BAO1A 1
Registered No.
FULL NAME Rena L. McKeen ( Fredericks )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Month)
(Day)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ..
Cerebral Hemorrhage
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 horder 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 elerk 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 sueh board, agent or elerk, 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 oceupation, 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).
OF TOM.
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 1. 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 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 aetion 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.
AUG - 51957 AH Statement 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
NORFOLK
(County) BROOKLINE (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
BROOKLINE
(City or Town making this return)
Registered No.
498 713
$ (If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
Ruth Lawrence (Harmon)
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