USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1957 > Part 49
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 35 Girdlestone Road
Winthrop, Massachusetts
St
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years.
months.
19days. In place of residence
20years.
months.
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July
3
1957
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
June 14
19
57
to
July 2
19.5.7
I last saw h.e.Talive on
July .... 2
19 .. 5.7., death is said to
have occurred on the date stated above, at
2:30 .... a
..... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .Cancer ..... of Bladder., ..... Urinary .......
with widespread metastases
Due To
INTERVAL BETWEEN ONSET AND DEATH
8 mos.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
female white
MARRIED
WIDOWED
or DIVORCED married
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
Arthur J. Lawrence
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.38 Years.9.
Months.
16 Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :.
Housewife
(Kind of work done during most of working life)
14 Industry
or Business
at home
15 Social Security No ...
16 BIRTHPLACE (City)
(State or country)
New Hampshire
17 NAME OF FATHER Asbra Harmon
PARENTS
18 BIRTHPLACE OF
FATHER (City) ... Madison (State or country) New Hampshire
19 MAIDEN NAME OF MOTHER Ada Ulven
20 BIRTHPLACE OF Salem
MOTHER (City) (State or country) Massachusetts
Arthur Lawrence
DATE OF BURIAL. July 5 1957
(Address)
35 Girdlestone Rd. Winthrop, Mass, 1
7 NAME OF FUNERAL DIRECTOR Ernest C. Caggiano
ADDRESS 147 Winthrop St., Winthrop, Mass
Received and
filed
AUG 12 1957
19
· ATTEST:
(Registrar of City or Town yhere death occurred)
DATE FILED
July 3
19 57
(Registrar of City or Town where deceased resided)
(1)) 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) resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
5031.11.55.916145
(Signed)
Raymond O. Olson
M. D. 270 Commonwealth Ave
(Address) Boston, ... Mass. Date. July 3 1957
Winthrop Cemetery, Winthrop. ...... Massachusetts Place of Burtal or Cremation (City or Town)
21 Informant.
A TRUE COPY
Madison
OTHER SIGNIFICANT CONDITIONS
W'as autopsy performed? What test confirmed diagnosis ?.... surgery.
5 Was disease or injury in any way related to occupation of deceased ?.... no .. If so, specify.
PLACE OF DEATH
302 1
CERTIFICATE OF DEATH
No. 227 Summit Avenue (Brooks Hospital)
2 FULL NAME
(Was deceased a
U. S. War Veteran,
if so specify WAR)
no
RECEIVED
TOW
1:
AUG 1 2 1957 KM
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)
14.46618
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.)
19 Coral Ave.
Winthrop
St
Mass .
(a) Residence. No ... (Usual place of ahode)
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years.
.months
16
.days. In place of residence .. 10 years.
months
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July 15/57
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended, deceased from
July 15
57
June 29 19
57
to
19
I last saw h.
imlive on
July 15
1957
death is said to
have occurred on the date stated ahove, at
11;20PM
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ? Pulmonary embolism
Due To (b))
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Congestive heart failure
coronary artery disease
Yrs
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
J Rankin
M. D
330 Brookline Ave,
Date.
7 -15
57
19
(Address)
Ahavis Achim Anshe Sfard Lym Mass.
6 Place of Burial or Crematf11- 16/57
DATE OF BURIAL. 19
7 NAME OF
FUNERAL DIRECTOR
Torf Funeral Service Inc.
Chelsea Mass.
ADDRESS TAUG 14 1957
Received and filed. 19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
W
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
10a If married, widowed, or divorced
HUSBAND of
Begsie Alter
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.
59 Years.
Months.
Days
If under 24 hours
Hours ..
Minutes
13 Usual
Occupation :
(Kind of weakKAPPl motHRAk
14 Industry
or Business :
Meat Packing
15 Social Security No ....
16 BIRTHPLACE (City)
(State or country)
17 NAME OF FATHER Harry Byne
18 BIRTHPLACE OF
Russia
FATHER (City) (State or country)
-
19 MAIDEN NAME
OF MOTHER
Celia
-
20 BIRTHPLACE OF
Russia
MOTHER (City). (State or country)
21 Informant. (Address)
Leo Cohen 19 Coral Ave Winthrop
-
A TRUE CORY les
ATTEST:
(Registrar of City or Town where death occurred) July 18/57 .. 19
DATE FILED
(Registrar of City or Town where deceased resided)
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 mouth in which the death occurred. (See Chap. 46, Sec. 12, G. L .. )
50MI.11 55.916145
302
1
No.
Beth Israel Hospt .
Myer Byne
(Was deceased a
U. S. War Veteran,
f so specify WAR)
PARENTS
(City or Town)
it. Macka99
X
idit
Chelsea Mass .
Yes
INTERVAL BETWEEN ONSET ANO DEATH 7 Hrs
AUG 1 41957 AM
>
PLACE OF DEATH
HAMPDEN (County) SPRINGFIELD
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
SPRINGFIELD
(City or Town making this return)
₹45
Hillcrest Nursing Home No.
§ (If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
Madeline (O'Donnell) Smith
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.) 20 Pleasant
sWinthrop
Vass
(a) Residence. No .. (Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.
........... years.
3
months.
........ days. In place of residence
2.years.
months
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July
24
1957
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY,
That I attended deceased from
22 July
19
57
to ...
24 July
19
57
I last saw
h.ºLalive on
23 July
19%, death is said to
have occurred on the date stated ahove, at
7: 20P
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Bronchopneumonia
(a)
(1))
Due ToCerebral Thrombosis
3Days
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed? What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed) John M Maloney M. D. (Address) 20 Haplo at Spfc Date. te 26 July 1957
Winthrop Cemetery Winthrop Mass 6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL July 27 1557
7 NAME OF
Richard J Hannigan
FUNERAL DIRECTOR 556 State St Spild mass
ADDRESS
Received and filed .. ..
AUG 16 1957
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED idowed
10a If married, widowed, or divorced
HUSBAND of
Joseph A Smith
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
1269
AGE ...
Years
Months ............ Days
If under 24 hours
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 ..
16 BIRTHPLACE (City) __ oston
(State or country)
17 NAME OF
FATHER
Montique O'Donnell
PARENTS
18 BIRTHPLACE OBBoston
FATHER (City)
(State or country)
MASS
19 MAIDEN NAME
OF MOTHER
Roso MeGilvrey
20 BIRTHPLACE OF
MOTHER (City) ... Jana
(State or country)
21
Paul Smith
Informant O Barrett St . SpfId
(Address )">
A TRUE COPY Clifford 20Smith.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Jul 30 1957
19.
50M1- 11.55.916145
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 deccased resided in another city or town Due To (c)
-302 1
-12/56
Registered No.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
INTERVAL
BETWEEN
ONSET AND
DEATH
1Day
AUG 1 G1557 AM
X
Suffolk
(County)
Winthron (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.
No.
142 Pleasant Str fera T
H
[(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.
(Usual place of abode)
2
142 Pleasant St.
St
(If nonresident, give city or town and State)
2
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
(Monthy
(Day)
1
1951
(Year)
4 I HEREBY CERTIFY,
4/1
19.
That I attended deceased from
circa 211
195
I last saw h, alive on
July 31 ), 195, death is said to
have occurred on the date stated above, at
34 m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
BRONCHO-PNEUMONIA
(a)
ARTRIO
(b)
Due To
CenterE SCLEROTIC
HEART DISEASE
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
0
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) Med à RRegan , M. D. 113 Pleasantit Wenthigh
(Address)
6 Winthrop
Winthrop
Place of Burial or Cremation DATE OF BURIAL
Aug . 5
19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed Gün: 5, 1957 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
"'emale
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widow
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
George Faulkner
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
80
2
Months
Days
24
If under 24 hours
Hours
Minutes
13 Usual
Occupation :
None
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
None
..
17 NAME OF
FATHER
James Osgood
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country)
mass
19 MAIDEN NAME
OF MOTHER
Milly Manand
20 BIRTIIPLACE OF
MOTIIER (City)
(State or country)
Kentucky
21
Informant
Clara Johnson
1 (Address)Framingham Lass
- I HEREBY CERTIFY that a satisfactory standard certificate of death .war-fled with me BEFORE the burial dr transit permit was issued :
(Signature of Agent of Board of Ilealth or other)
8/5/55
301A 1
10NS
TIFICATE
ng DEATH nter i one each and (c)
not mean / dying, t failure, It means r compli- i caused
if any, rise to e
(a). under- last.
contrib- but not terminal ion given
pter 137, requires print or cause leath on
rates.
SOM-5-56-917573
PLACE OF DEATH
2 FULL NAME
Vesta (Osgood ) Faulkner
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Registered No.
d
AGE
Years
16 BIRTHPLACE (City)
(State or country)
MASS
Boston
PARENTS
اكور
(City or Town)
INTERVAL BETWEEN ONSET AND DEATH 2 DAYS
3 cje
(Official Designation) (Date of Issue of Permit)
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.
---
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 be has received a permit from the board of health, or its agent appointed to issye 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 forin 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 heen 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 he 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).
RECEIVED
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the follow- hig rules of practice:
(1) / Attending physicians will certify to such deaths only as those of persons to whomthey have given bedside care during a last illness from disease unrelated tto.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 duy tortury. "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.
AUGcard195 Cluse of Death,-Physicians: see explanatory instructions 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
Middlesex (County)
Cambridge
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Cambridge
(City or town making return)
Registered No.
1131_17
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME ..
eorre 'ashington Ward
(If deceased is a married, widowed or divorced woman, give also maiden name.)
40 Ocean Avenue
St.
winthrop ...
Migss.
(If nonresident, give city or town and State)
Length of stay: In place of death.
.. years.
months.
7
12
days. In place of residence.
.years
months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August 1. 1957.
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.)
Acute coronary throminais
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
53
Years
Months.
22.Days
If under 24 hours
Hours.
Minutes
14 Usual
Occupation1.
Chief To inger
(Kind of work done during most of working life)
15 Industry
Drede
or Business:
022-03-1933
16 Social Security No ...
ansloro
17 BIRTHPLACE (City).
(State or country)
Carolina
18 NAME OF
FATHER
Davil G. Ward
19 BIRTHPLACE OF
FATHER (City)
a sporo
(State or country)
orth Carolina
20 MAIDEN NAME
OF MOTHER
un" Moore
21 BIRTHPLACE OF
MOTHER (City)
sans oro
(State or country)
forti Carolina
.
Informant
(Address)
10 Oc a. introp
A TRUE COPY.
Jaénical H. Burde
ATTEST:
(Registrar of City or Town where death occurred)
Aus. 2,
DATE FILED
(Registrar of City or Town where deceased resided)
PARENTS
6 Was disease or injury in any way related to occupation of deceased? ...
If so, specify
(Signed)
Peter si. Delmonico
M. D.
(Address)
Tolmont, 73, "ass. Date /1/
197
Janstaro cton
7 Place of Burial, or Cremation. (City of Town)
Jul ah ord
DATE OF BURIAL .. Av :- 5, 97
8 NAME OF
FUNERAL DIRECTOR
Intimo,,"ass
ard 9. 2polis
ADDRESS
Received and filed
AUG KI WWI
19
9 SEX
10 COLOR OR RACE
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
11a If married, widowed, or divorced
HUSBAND of.
byloah
noten
(Give maiden name of wife in full)
and bronchioperic carcinoma
with
videsore I metase cos.
5 Accident, suicide, or homicide (specify).
Date and hour of injury.
19
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public place?
(Specify type of place)
Manner of
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed?
Yos
NO
25m-(h)-10-48-24658
PLACE OF DEATH
M R-305 1
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 at the time after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided as soon as possible
No.
Mount Auburn Hospital
(a) Residence.
No.
(Usual place of abode)
ALout
(Was deceased a
U. S. War Veteran,
[if so specify WAR)
(write the word)
AGE
19 57
-
.1
AUG 2 71957 /11
X
PLACE OF DEATH
uffilk (County) Ministrul (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.
Registered No. 118
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)
Nintil
St.
(If nonresident, give city or town and State)
Length of stay: In place of death.
Gears.
months
days. In place of residence.
... years
months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
aucune+ 2, 19551
(Months
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
18 July, 1952, to
>
August
1922
I last saw hetakve on
2 August, 19 1), death is said toll
have occurred on the date stated above, at
5 30 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Chronic Myocarditis
(a)
over 5 years
Due To
Strong Endocarditis
Giver 5 years
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?.
110
What test confirmed diagnosis? Clincal EXAM
5 Was disease or injury in any way related to occupation of deceased ? / { If so, specify ... ).
(Signed). 27 Binning To It Riveri ('Address)
Date
Malden
Place of Burial or Cremation (City or Town) DATE OF BURIAL CELLCHOL 6 1927
7 NAME OF FUNERAL DIRECTOR- Je Le haya game
ADDRESS
AUG 7 1957
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Imali
9 COLOR
Muli
10 SINGLE
(write the word)
MARRIED
WIDOWED
Y DIVO
ormale
4
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 /5 Years.
Months
Days
If under 24 hours
Hours_Minutes
13 Usual
Occupation :
Checker
Patrice
14 Industry
or Business:
industris
15 Social Security No ..
1023-03- 0204
16 BIRTHPLACE (City)
(State or country)
Charleston Man
17 NAME OF
FATHER
firethe fancy
18 BIRTHPLACE OF FATHER (City) (State or country)
19 MAIDEN NAME OF MOTIIER
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.