USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1957 > Part 92
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SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE. RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-302 1
PLACE OF DEATH
(County)
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
Registered No.
266
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
BERNARD B. WOOD
2 FULL NAME
( Was deceased a
ar Veteran, cify WAR)
ly or town and State)
S.
L PARTICULARS
SINGLE (write the word) MARRIED WIDOWED or DIVORCED
e of wife in full)
name in full)
If under 24 hours
Hours ........ Minutes
....
ring most of working life)
from July 30
19 57, to October 18 10 57
and last saw h ... i.m alive all.2 .: Q5Aon .... Oct. 18 .19.5.7.
b. Kind of Business or Industry in which this work was done
15.
7 SOCIAL SECURITY NO.
& BIRTHPLACE (State or Foreign Country)
Mass.
9 OF WHAT COUNTRY WAS DECEASED A CITIZEN AT TIME OF DEATH?
U.S.A.
104. WAS DECEASED EVER IN UNITED STATES ARMED FORCES?
10b. 19 YES, Give war or dates of service .
Witness my hand this. 1&day of ........ October.
.. .. 19.5.7 ...
11 NAME OF FATHER OF DECEDENT
Freek Work
Signature Frank & French
M. D.
Frank S. French
Address .U. S.Public Health ... Serv.Hosp .. , S .. I.N
TypAcci,
13 NAME OF INFORMANT
RELATIONSHIP TO DECEASED ADDRESS
Wathop
Serons Word
14e. Name of Cemetery or Crematory like to Natx Con
14b, Lovation (City, Town or County and
14c. Data of Burial or Cremation 20 26/57
31 FUNERAL DIRECTO
LOMAS E. HALTON
AYE FOR AL PARK
BUREAU OF RECORDS AND STATISTICS
DEPARTMENT OF HEALTH
THE CITY OF NEW YORK
-
·n where death occurred)
(Registrar of City or Town where deceased resided)
25M-8-56-916227
Rev. 9/94) = 142 5 Institution 8 Area-Dist Caute 1 Cause 3 Operation resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Att-Autop.
......
Certificate of Death
Bore Death
FILED
RICHMOND
Certificate No.
W
-BERNARD
WOOD
Middle Name Last Name
PERSONAL PARTICULARS, (To be filled in by Funeral Director)
MEDICAL CERTIFICATE OF DEATH (To be filled in by the Physician)
Boro-Recid.
2 USUAL RESIDENCE: (s) State ....
MASS.
(c) Post Office uus and Zone.com
WINTHROP
(d) No. 3.2% Presset
it
Ave Ist
(If in rural area, give location) (e) Length of residence or stay in City of New York immediately prior to death por Res.
V01341
3 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word)
Murrenit
Nattv. Dec.
4 DATE OF BIRTH OF DECEDENT
(Month) 8 -
(Day
(Year)
8-191
$ AGE
If under 1 year
If LESS than 1 day,
dayı
hrs. or
a. Usual Occupation (Kind of work done during most of working Life, even if retired)
31-
Occupation
(If nos in hospital or institution, gios street and number.)
(d) If in hospital, give Ward No. B-2
16 DATE AND HOUR OF DEATH
(Month)
(Day)
(Year)
Oct.
18
1957
(Hour) 12:05A.
17 SEX
male
18 COLOR OR RACE white
19 Approximate Age 40
20 I HEREBY CERTIFY that (+attended the deceased)"
(a staff physician of this institution attended the deceased)*
I further certify that death + .... wa.s ... not ......... caused, directly or indirectly by accident, homicide, suicide, acute or chroule poisoning, or in any suspicious or unusual manner, and that it was due to NATURAL CAUSES more fully described in the confidential medical report filed with the Department of Health.
· Cross out words that do not apply. t See frat instruction on reverse of cortigente.
12 MAIDEN NAME OF MOTHER OF DECEDENT
Underan.
=
OCELITance
ec'd -31-58
FOR STATISTICAL PURPOSES ONLY FOR A CERTIFIED COPY APPLY TO DEPARTMENT OF HEALTH NEW YORK, N. Y.
(City or Town making this return)
156-57-501830
3? 1. NAME OF DECEASED (Print or Typrurite)
First Name
15 PLACE OF DEATH?
(s) NEW YORK CITY : (b) Borough ....... Richmond
(b) Comme
U. S. Public Health Serv. Hos
(c) Name of Hospital or Institution .rundt Staten Island N.Y.
No ..
ADDRESS
DATE FILED ............
19
ฮู้
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, G. L .. )
X
Suffolk
(County)
Revere
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
2/7
Revere
(City or Town making this return)
26.
§ (If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
1
2 FULL NAME Eve J. Kenney (Wallace) (If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years ....
months ............ days. In place of residence. 2 .... years
.months
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
December
30 Day)
1957
( Year)
(Month)
(Day)
4 1 HEREBY CERTIFY,
That I attended deceased from
April 8,
53.
to .. Dee -........
30
197
I last saw @r .... alive on ... De.c ... 29 1957, death is said to have occurred on the date stated above, at 6: 0.5A ... .. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(Acute Pulmonary ..... Edoma
INTERVAL BETWEEN ONSET AND DEATH thrs.
Due (b) Congestive heart
lyr.
failure
Due
(c) CardiacEnlargement
byrs.
OTHER
SIGNIFICANT
CONDITIONS
1
Was autopsy performed ?.
no
What test confirmed diagnosis ?.
Clinical
5 Was disease or injury in any way related to occupation of deceased? n.O. If so, specify.
(Signed) Guy ..... A ........ DiStasio M. D.
(Address)
2.21 Peach St.
Dat 2/30
15.7
Revere
Winthrop
Winthrop Place of Burial or Cremation (City or Town)
DATE OF BURIAL January 2.
598
7 NAME OF FUNERAL DIRECTOR Arthur J. O' Maley Winthrop
ADDRESS
Received and filed. JAN 17 1958 19
(Registrar of City or Town where deceased resided)
8 SEX
emale
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED dowed
or DIVORCED
(write the word)
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFI
Nicholas E. Kenney
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGE
Years.
Months.
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupati
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City) Boston
(State or country)
Mass
17 NAME OF
FATHERWilliam Wallace
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Meine
19 MAIDEN NAME
OF MOTHER
Catherine Forshner
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Pennsylvania
21 Eva Mccarthy
Informant.
(Address] 6 Fondoin St
Winthrop
A TRUE COPY
ATTEST:
20, 67
(Registrar of City or Town where death occurred)
DATE FILED
December
31
19
57
PARENTS
25M-0-56-918227
PLACE OF DEATH
R-302 1
Registered No.
No Rovere Memorial Hospital
(a) Residence. No.16 ..... Bowdoin ... St .. (Usual place of abode)
1
-
JAN 1 71958 18
Wihr Uto
Suffolk (('onnty)
Boston
DIVISION OF VITAL STATISTICS STANDARD
Nn. The Bakar Memorial James D. Mc Phail 2 FI'LL. NAME
(If dereamed is a married, widowed or divorced woman, give also maiden name )
(a) Residence. No 6 Grovers Ave.
winthrop, Mass.
( If nontrident, give city in town and State)
Length of alay: In place of death Yanı.
months 2 days In place of realdeme 2
MEDICAL CERTIFICATE OF DEATH
I DATE OF October 39. 1957
DEATH
( Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
That attended deceased from
Oct. 27 .19 $ 7. to
Oct. 29
57
I Just saw himalive nn
Oct. 29
. 39 57, death is said to
have occurred on the date slated alinve, at 11 : 55. m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(.)Pulmonary edema, severe
(b)
Due Tn
Coranary heart disease,
severe.
Due Tn
(c)
120.1
OTHIFR SIGNIFICANT CONDITIONS
Was antopsy perlormed' yes (limited)
What test confirmed diagnosis?
limited autopsy
S Was disease or injury in any way related to occupation of deceased? 11 .0. sperify No
(Signed)
Oh Clay
, M. D
OF MOTHER
MARY
BREEN
-
ASST .. DIR. MASS GEN. RAED.
. GAM GRIVE
NEEDFORI)
(('ity er Tuwn)
Place of Burial of ('remation DATE OF NURIAL Nor. 2
7 NAME OF
ADDRESS
Received
NOV 5 1957 Charles H. Lack
( Registrar)
A SEX
MALE
WHITE
A SINGLE (warte the world
MARRIED
WIDOWED
OF DIVORCED MARRIED
10a If mattied, wie
ISABELLE C. KENNEY
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLHORN, enler that fact here.
unk. Occupation :
( Kind of work done during most of working file)
14 Industry
nr Business:
LUMBER
IS Social Security No
I6 BIRTHPLACE (City)
EAST BISTON
( State of country )
MASS
17 NAME OF
FATHER
JAMES & MC PHAIL
PARENTS
18 BIRTHPLACE OF
EAST BÜSTEN
FATIHIR ('ity)
(State of country }
MASS
19 MAIDEN NAME
D BIRTHPLACE OF
MOTHER (City)
EAST BOSTON
MASS
(State of country )
21
MAS. ISABELLE MC PHAIL
(Address) CERCVERS AVE WINTHROP.
Infiniant
I HIERE.DY CERTIFY that a satisfactory Handlaril certificate nf death was fred with me BEFORE the lamajor transit perry was issued =
«
ʻ
4503 11/1/578 -
(Official Designation )
( Date ol lsane off'ermit)
.
-301A -
TIONS
TIFICATE
Ing DEATH entar . ... each and (c)
... .... of drink . et fadure.
no compli.
1
if .. v. (a).
& but mot
pter 137. requires print er ause of est. .. tas.
PLACE OF DEATH
EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTHUT - OF-TOWN
To be nied for burial permil with Hoard of Health
Registered No.
fill death mcomted in a husjutal oc institution. St give ita NAME. instead of street and number)
PHYSICIAN IMPORTANT
I' S War Veteran, if Att aprtify WAR,
II ....
=
-
....
INTERVAL BETWEEN ONSET AND 12 DEATH unk. mins AGE: 41 Years
--
PERSONAL. AND STATISTICAL PARTICULARS
-
Months
Days
If under 24 hours
Hours
Minutes
13 l'qual
SALSEMAIN
years
HUSBAND of
2 268
2
...
19
( l'anal place of aloode )
'A TRUE COPY ATTEST: Charles it Macke City Ben star
1
. ...
6
?
FEB 211958 TM
1
PLACE OF DEATH
Suff olk (County)
Boston (('ily nt Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT - OF - TOWN To be flied for burial permit with Board of Health of Ba Ageni 10403 Registered Nn.
No. Veterans Administration Hospital Louis J. HARRINGTON 2 FULL NAME
Jill death accused in a hospital or institution, St. FRIVe IT. NAME instead of stert and number) PHYSICIAN IMPORTANT
(II deceased is a married, widowed or divorced woman, give also maiden name )
(a) Residence.
Nn.
25 Johnson Ave.,
(\'qual place of abode )
&. Winthrop,
Massachusetts
(II nonresident, Rive city of town and State)
Length of stay! In place nf death years
months
-1days. In place of residence
35 car«
months
days.
MEDICAL CERTIFICATE OF DEATHI
3 DATE OF
DEATH
November
9,
1957
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
That A attended deceased Irmm
November 8,. 1,57
, In
November 9,
. 19 57
have occurred on the date stated above, at 2:20 A.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
() 1. Pulmonary congostion and
edema .
Une To
(11)
2. R.cont posterior
myocardial in arction.
Due To (c)
Cardiomcaly-800 grams
OTHER SIGNIFICANTCarcinoma of prostate with CONDITIONSvertebral metastases. voors
Was autopey performed'
Y03
What test confirmed diagnosis?
Autopsy
5 Was disease or injury in any way related to necupation of deceased ? Io If so. specify
(Signed)
. M. D.
(Adress) VA Hospital, Poston Mar Nov. 9
1257
7 NAME OF
FUNERAL DIRECTOR
"'aurico W. Virby
ADDRESS 210 Winthrop St. .. inthrop. lass . AOV 14 1957 . Charles H. Machine" ( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
R SEX
9 COLOR
10 SINGLE
( write the word)
MARRIED
WIDOW EDWid owed
of DIVORCED
Nale White
10a If married, widowed, or divorced
HUSBAND of
i ruch
nie Cann
(Give maiden name of wife in Full)
(or) WIFE. ol
( Hushand's name in full;
11 IF STILLBORN, enter that fact hete. 12
Il under 24 hours
Hour.
Minutes
Accountant
(Kind of work done digging most al winking lite)
14 Industry
Dr Business:
Caval
15 Social Security Nn.
16 BIRTHPLACE (City)
( State of country)
Massachusetts
17 NAME OF
FATHER
Edward Harrington
PARENTS
18 MIRTIIPLACE OF
Lowell
FATHER (f'ily)
State of country!
T'assachusetts
19 MAIDEN NAME IF MOTHER "ary Coliton
D BIRTHPLACE OF
MOTHER (f'ily)
(State of country }
Cambridge
Massachusetts
6 Oak Grove Cemetery, Codford, inss.
Place id Burial or Cremation
DATE OF BURIAL
Novombor 11
1.57
(''ity ar Town)
21
Informant
VA Hospital Ricordo
(Alle:)150 So Huntington Avc., Doston
I HEREBY CERTIFY that a satisfactory standard certificate of death
bled with me IttMORE the final of
All vermell was posted
Les; SI.E
Liderail N 18462
Kov 10 195) .
(O)thcial Designation )
(Date of Issue of P'ermit)
-
day
yours
Cambridge
ih but ant e terminal
.
last
apier 137. I. requires to print er ..... . f death .. cales.
.1 or
iction
SOM-3-37-920345
209 5
R-301A -
TIONS R RTIFICATE ving DEATH enter
t each and (c)
01 dying.
(a)
42011
INTERVAL
BETWEEN
ONSET AND
DEATH
day
AGE. 68 Years 5 Months
lbay.
..
..
( Was deceased a U. S. War Veteran,un if so specify WAREN I -
A TRUE COPY ATTEST: Charles it Mackie City Registrar
RECEIVE
-
FEB 2 11958 1X
1
PLACE OF DEATH
SUFFOLK (County)
BOSTON
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No
Salvatore Lupoli 2 FULL NAME ..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(*) Residence. No
138 Partlett Road
(l'aval place of abode)
Length of stay: In place of death
years
months
days. In place of residence
years
month«
day
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
R SF.X
male
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED
of DIVORCED
married
10a If married, widowed, or divorced Gelsimina Materese
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE. of
( Ilusbaud's name in fall)
11 IF STILLBORN, enter that fact here.
12
AGF: 39
Years
Months
Day«
If under 24 hours
Minutes
13 I'sual
Self Employed
Occupation :
(Kind of work done during most of working lite)
Proprietor Grocery Store
15 Social Security No.
Unknown
16 BIRTHPLACE (City)
(State of country )
Italy
17 NAME OF
FATHER
Nicola Lupoli
PARENTS
18 BIRTHPLACE OF
FATIIER (City)
(State of country)
Italy
19 MAIDEN NAME
OF MOTHER
Sylvia (unknown)
201 11RT11PLACE OF
MOTHER (City)
(State of country )
Italy
21 Gelsimina Lupoli (wife) Informant (Address) 138 Barlett Rd. , Winthrop, kass. IEREBY CERTIVS' that a satisfactory standard certificate of death Was hled with me HE.FORE the burial or ti ypqit pesant was jeour wishErhard AlsqTE =
(Official Designation)
flinte of lasse of l'ermit) ...
-
3 DATE OF
DEATH
November
9,
1957
(Year)
(Month)
(Day)
4I HEREBY CERTIFY.
ThaWOattended deceased from
November9 19 57 November 9,19 57
. 19
Id last saw himfalive on November 9
. 19 57 , death 1% said to
have occurred on the date stated above, at 2:50 A.
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cardiac Tamponade
( Hoemo Pericardium )
3 hrs
Due To Dissecting Aneurysm of the
(b)
Aorta
Due To (c)
451
Was autopay performed' What test confirmed diagnosis?
I Was disease or injury in any way related to occupation of deceased?
If sn, specify
·
(Signed)
( Address) Asst . Dir . Mass . Con'lar.
, M. D)
19
6
St. Michael Cemetery
Place of Ilurial or Cremation
City or Town 1
November 13, 57
19
7 NAME. OF
FUNERAL DIRECTOR
9 Chelsea 3t., East Boston, Kass.
Received IJOV 19 1957 Charles H. Mackun
J (If death occurred in a hospital or institution. St. (give ita NAME instead of street and number) PHYSICIAN IMPORTANT
(Was decreased a IS War Veteran, NO
11 sn specify WAR)
Winthrop,
Mass .
St.
(If nonresident, give city of town and State)
...
ATIFICATE
Ing
DEATH enter .. ... r each and (c)
sof .... of dying. rt ledere.
rile to (.). weder. se last.
, contrib. & det sof terminal
apter In. , requires to print er cause or Mesth .n cates.
-301A 1
TIONS
870 2
with Board of Health
No.
MASSACHUSETTS GENERAL HOSPITAL
Vincent "apino
Boston
DATE OF BURIAL
INTERVAL BETWEEN ONSET ANO DEATH
3 hrs
14 Industry
or Business
OTHER SIGNIFICANT CONDITIONS
A TRUE COPY ATTEST:
Charles H . Mackie City Re car
RECEIVE
TOWA
41.12.7
6
FEB 21 1958 FM
1
PLACE OF DEATH
Suffolk (County )
BOSTON (( ity or lownl
Beth Israel No Sidney Gordon 2 FU'1.1. NAME
(If deceased is a married, widowed or divorced woman, give also maiden name. )
24 Trident
(a) Residence. No. (['qual place of ahode)
Length of stay: In place of death years months
days In place of residence months days.
MEDICAL. CERTIFICATE OF DEATH
J DATE OF
DEATH
Nov
(Month1
1957
(Year )
4IHEREBY CERTIFY.
That 1 attended deceased firm
Nov
10
, 1057
in
NOV
10
I last saw him Alive on
Nov
10. 1957, death is hard to
have occurred on the date stated above, at
3 A
m
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Anoxia
Due To
Bronchial asthma
(11)
Due To (c)
SIGNIFICANT
OTHER
Diabetes mellitus
CONDITIONS
arteriosclerosis heard discede
Was autopsy performed?
no
What test confirmed diagnosis?
none
S Wan disease of injury in any way related to occupation of deceased?
If so, specify
no
(Signed)
Paul R. mintos
, M. D.
(Address) 330 Brookline Ave Date Nov 10 1- 59
Agudath Achim
Woburn
Place of lurial or Cremation
(City of Town)
Informant
DATE OF RU'RIAL
November 10,
57
21
Dora Gordon
Very, 24 Trident Avc., Winthrop
7 NAME OF
FUNERAL DIRECTOR
Benjamin Birnbach
ADDRESS
10 Washington St. Dorchester
NOV 19 1957
Received
Charles H. Mackie
PERSONAL AND STATISTICAL. PARTICULARS
A SEX
Male
White
10 SINGLE
Iwrite the words
MARRIED
Married
of DIVORCED
la If married, widowed, tomat katz
111'SHAND Af
(Give maiden name of wile in falli
(or) WIFE of
(finsband's name in full)
11 IF STILLHORN, enter that fact here.
Yrale Months Days
If under 24 hours
11 .1117%
Minutes
Sexton
( Kind at was done dung mest of work .; ! te)
14 Incluretry
Cong. Trforeth Israel
15 Social Security No.
027-16-0239
16 111R1111L.ACE (City)
Russia
(State or country ]
17 NAME OF
FATHER
Moses Aaron Gordon
18 WIRTIIPLACE OF
Russia
FATIIER (t'ity)
( State or , mintiv)
19 MAIDEN NAME
OF MOTHER
Deborah Lipsky
DO BIRTHPLACE OF
MOTHER (City)
(State or untntry )
Russia
filed with me BEFORE the final of leguan peninit was soleil 1 19101111 at at Hoped of 11.
18415-
Gibral Designation)
( Date of lesue af P'ermit) ...
Kongred 3-13.58
PARENTS
The Commonwealth of Massachusetts EDWARD J. CRONIN
SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
OUT - OF - TOWN To be fir f far burial primit with l'ont of Health
STANDARD
CERTIFICATE OF DEATH Hospital
PITY' ICIAN IMPORTARI
No I' S War Veteran. if so specify WAR)
Ave
Winthrop, Mass
St.
( If nonresident, give city of town and State!
CERTIFICATE
lving OF DEATH t enter ban one for each b) end (c)
... ... .... 01
It meant
Air A
11 @ny.
raik but not the formand
lait
Chapter 137, 54. requires t to print of cause death ..
MED. EXAMINER
R.301A 1
UCTIONS
=
INTERVAL
BETWEEN
ONSET AND
DEATH
2 hrs
12
64
yrs
241
Yrs
A TRUE COPY ATTEST: Charles it Mackie City Registrar
RECE YSO
1 !
1
-
3
FEB 211958 MM
1
X
PLACE OF DEATH
SUFFOLK BOSTONty)
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
272
272
BOSTON. (City or town making returp) 10787
Registered No.
J(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.)
(Was deceased a
U. S. War Veteran,
209 289 Shirley St
Winthrop Mas's.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
.years.
1
months.
days.
In place of residence.
... years.
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR OR RACE
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
Jennie M Bartlett
(write the word)
Married
(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.) Fracture of hip 'broncho
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
92
13
AGE
Years
Months .... Pays Works THE
If under 24 hours
Hough. .... Minutes
14 Usual
Occupation :
(Kind Fire Workgst of working life)
15 Industry or Business:
16 Social Security No ..
Boston Mass
17 BIRTHPLACE (City).
(State or country)
18 NAME OF FATHER
19 BIRTHPLACE OF
Rochester N H
FATHER (City) (State or country)
20 MAIDEN NAME
OF MOTHER
Salom Mass
Ellen M Bickford
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Wife
22 Informant (Address)
A TRUE COPY.
ATTEST
Charles & Track
(Registrar of City or Town where death occurred)
DATE FILED
Feb/14/57
19
......
(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)
Richard Ford
(Address) Date. .19.
Winthrop Cem-Winthrop Mass
7 Place of Burial, or Cremation No v. 20/57 (City or Town)
DATE OF BURIAL. 19
8 NAME OF
FUNERAL DIRECTOR
M W Kirby
ADDRESS Winthrop Mass
Received and filed. 19
25m-(c)-11-49-900.475
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
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.)
Manner of
(Specify type of place)
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed?
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?
pneumonia senility
accidental fall on sidewalk
Winthrop Sept. 11/57
3 DATE OF
DEATH
NOV. 17/57
if so specify WAR).
(a) Residence. No. (Usual place of abode)
George F McDuffee
Hill Top Hospt No.
M R-305 1
George F McDuffee
RECEIVE
٠٠
1
6
انات
FEB 2 41958
٦
MR-301A 1
PLACE OF DEATH
SUFFOLK (County)
BOSTON
(City or Town)
CERTIFICATE OF DEATH
MASSACHUSETTS GENERAL HOSPITAL
No.
2 FULL NAME HAUSER, Alice
(if deceased la a massed, widowed or divorced woman, give also maiden name )
(a) Residence. No. 435 Shirley St., Winthrop, Mass. ( L'aval place of ahore)
(If nonresident, give city of town and State )
Length of stay: In place of death yenTy months days. In place of residence years months days,
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX 9 COLOR
10 SINGI.E. (write the word)
MARRIED
WIDOWED
of DIVORCED
10a If married, widowed, or divorced HUSHAND of (Give maiden name uf wife in full)
. -..
(off WIFE, af
(Ilusband's name in full)
11 IF STILL.HORN, enter that fact here.
12/7
AGE
Years
/WK
1
Months
17,
Days
If under 24 hours
Hours
Minutes
13 I'siral
Occupation :
(Kind of work done during most of working life)
14 Industry
IS Social Sremity No.
*71.5
237
16 BIRTHPLACE (City),
10
(State of country)
17 NAME OF
FATHER
IR BIRTHPLACE OF
naplo tonitein
FATHER (City) (State of country)
19 MAIDEN NAME OF MOTHER
20 BIRTHPLACE OF MOTHER (City) (State or country )
nil to obtain
19 21 Infin mant (Address)
I HEREBY FFREILY that a satisfactory standard crititicate of death wA. I. with me Itt FORE. the burial of transit primot gas lasted
- 4961 12-2-57
(Official Designation)
( Date of Issue of Permit)
11221
Registered No.
J(If death occurred in a hospital or institution, St. [Rive its NAME, instead of street and number) PHYSICIAN IMPORTANT
( Was deceased a IS Was Veterant, if so sperify WAR)
CERTIFICATE
giving OF DEATH ant enter than one for each (b) and (c)
. n' disme. heart failure. = " no compli
.... lait
Tinni contrib death Aur ant
Chapter 137. 1954, requires na to print er e cause er of death en rtincates.
SOM 2 27.920345
6 Place of Burial or Cremation
DATE. OF BURIAL
Dor.
DLC 4 1957
Received atil still charles H. I nacks
INTERVAL BETWEEN ONSET AND DEATH
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis'
yes autopsy
S Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
. M. D
(Address) Asst . Dir . "ass .Gen' ],Jale Dec. 1,1, 57
(City of Town]
7 NAME OF
Nov.
30
1957
(Mm.th)
(Day)
(Year)
4 I HERERY CERTIFY.
Nov. 29 1 57. to
NOy,
30
Ci last saw Gr alive on Nov.
30,.657
. 19
57
denth is said to
have occurred on the date stated above, at 10:25P.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Bronchopneumonia,
bilat., ackte, Severe
J DATE OF
DEATII
RUCTIONS
EDWARD J. CRONIN
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