USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1958 > Part 91
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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 for 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.
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
ome when the certificate of death is needed.
BOL 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 USN
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE.
Dec. 9,1949
Sept.30,1952
RANK, RATING
Stock Clerk
ORGANIZATION AND OUTFIT
USN
SERVICE NUMBER
751 80 69
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 filled for burial permit with Board of Health or its Agent.
263
2 FULL NAME
Walter E .Daw
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
362 Shirley St
St
(If nonresident, give city or town and State)
Length of stay: In place of death;
1
.. years
6
.months.
days. In place of residence.
50
ears.
months.
.......
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
December 29. 1958
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
38
19.5.8
to
12/29
That I attended deceased from
12/25
19
I last saw hifkalive on
12/29
19.58, death is said to
have occurred on the date stated above, at
130 P
.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
PNEUMONIA - RT. LUBAR
(a)
INTERVAL BETWEEN ONSET AND DEATH 2 DAYS
5YRS
Due To
GENERAL ARTERIOSCLEROSIS
54Kg
OTHER
SIGNIFICANT
CONDITIONS
NONE
Was autopsy performed?
No
What test confirmed diagnosis ?..
CLINICAL
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify.
(Signed)
(Addre
222 Plement St Cristiano 12/29/1955
Winthrop
Winthrop
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
December 31. 19 58
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
Winthrop Mass.
ADDRESS
Received and filed 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED rried
or DIVORCED-
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
Delia A. Cassel.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGI88
Years.
Months ...
.Days®
If under 24 hours
Hours ........ Minutes
13 Usual
Retired Plumber
Occupation :
(Kind of work done during most of working life)
14 Industry
Plumbing
or Business :
15 Social Security No ....
16 BIRTHPLACE (City)
(State or country)
England
17 NAME OF
FATHER
Cannot be learned
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country)
England
19 MAIDEN NAME
Myron b. King
M. D.
OF MOTHER
Cannot be learned
20 BIRTIIPLACE OF
MOTHER (City)
(State or country)
England
21 Robert T. Daw
Informant
(Address)
362 Shirley St Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was Klech with the BEFORE the burial or transit permit was issued: Halkla @ Jverannex Signature of Avent of Board of Health or other)
Health Office
12/30/58
(Official Designation )
(Date of Issue of Permift)
V.V.A
301A 1
ONS
TIFICATE
ng DEATH nter one each and (c)
not mean dying, failure, It means r compli- caused
if any, rise to (a), under- last.
contrib- but not terminal ion given
apter 137, requires o print or cause or death on cates.
100M. 11.55-916145
-
Due To
ARTERIO SCLEROTIC HEART
(b)
DIS
(c)
(Usual place of abode)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
No
9}(If death occurred in a hospital or institution.,
142 pleasant Stwotheop Corals ers No.
Registered No.
Paignton
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith. after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- te ·n, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged. insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery. until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six. that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .-- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
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 undertaketof 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, Sed 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) Medicai 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, of 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
......
PLACE OF DEATH
Suffolk (County) Brighton (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
OUT- OF - TOWN To be filled for burial permit with Board of Health-} or its Agent.
264
CERTIFICATE OF DEATH
St. Elizabeth's Hospital
No. (15) Ethel Lloyd (Mr Laughlin)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.) 9. Albert AUR
St.
Winthrop
if so specify WAR)
,Mars.
(a) Residence.
No. ...
(Usual place of abode)
2 hrs
36
(If nonresident, give city or town and State)
Length of stay: In place of death_years O months O days. In place of residence
.years.
„month8.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
widowed
or DIVORCED
IOa If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
George 0. Lloyd Sr.
(Husband's name in full)
1I IF STILLBORN, enter that fact here.
12
AGE
Years
4
If under 24 hours
.. Hours ...... Minutes
Housewife
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
at home
15 Social Security No. C.W PU
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHE
Michael McLaughlin
18 BIRTHPLACE OF
East Boston
FATHER (City)
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Annie Call
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Bangor
Naine
21 Mrs. June Doherty
Informant
(Address)
9 Albert Ave. Winthrop
7 NAME OF
FUNERAL DIRECTOR
Ernest P. Caggiano
ADDRESS-
147 Winthrop St., Winthrop
Received and
HOV 17 1958 Charles & mackie (Registrar)
yrs.
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
yes
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so. specify.
No
(Signed).
John F. Lee MD
(Address)
M. D.
St. Plyabertis Hos Date Nov 7 1958
6 Winthrop Cemetery, Winthrop Place of Burial or Cremation
DATE OF BURIAL
November 11,
1958
(City or Town)
5014-1-58-921876
.301Å 1
ICHS
TIFICATE
DEATH nter one each and (c)
not mean f dying, t failure, It means , compli- 3
1/2
contrib. but not terminal Ion given
pter 137. requires print or ause or leath on ates.
1959
3 DATE OF
DEATH
Nov.
7
1958
(Year)
(Month)
(Day)
4 I HEREBY CERTIFY.
That I attended deceased from
Nov. 7. 1958
19
to
Nov. 7
SE
I last saw h."Salive on
Nov. 7
-, 19_JS, death is said to
have occurred on the date stated above, at ...?___ A.m.
INYE .. VAL
BETWEEN
ONSET AND
DEATH
2 hrs
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Intracerebral hemorrhage
Due To arteriosalandia cerebral (b) Artdes.
Due To
(c)
severe hypertension
PARENTS
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: William & Have (Signature of Agent of Board of Health or other)
00006
11/10/58
(Official Designation)
(Date of Issue of Permit)
Registered No.
10522-
el.
[(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,
no
.63
2
Months
Days
cast Boston
rise to (a). under- last.
City Registrar
RECEIVED
1
FEB - 21939 AM
X 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 MEMORIAL
OUT - OF - TOWN To be fled for burlal permit . with Board of Heeft> or its_Agent. 10999
Registered No.
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)
(a) Residence.
No ..
(Usual place of abode)
15_ Balcher
St.Winthrop
Massachusetts
(If nonresident, give city or town and State)
Length of stay: In place of death .....
years [ . months] 6 days. In place of residenc5.5 ... years ...
... months ...
...... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED Widowed
or DIVORCED
female
white
Ia IT married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .Albert Edward Johnson
(Husband's name in full)
11 IE. S
BORN, enter that fact here.
1
AGEZ.Z_ Years.
4 Months
1_Days
If under 24 hours
.Ilours .... Minutes
13 Usual
Occupation :
hold Siewie tohe during most of working life)
14 Industry
or Business :
own Come
15 Social Security No ....
none
16 BIRTHPLACE (City)
(State or country)
Gloucester,
17 NAME OF
FATHER
Thomas Shields
18 BIRTHPLACE OF
FATHER (City). (State or country) Wales
Seezestown
19 MAIDEN NAME OF MOTHER Annio Carrigan
20 BIRTIIPLACE OF
MOTHER (City) ...
Cork
(State or country)
Ireland
21
Informant
Mrs ..... Edward B ._ Wider
(Address)
09 Upland-Rd-
I HEREBY CERTIFY that a satisfactory ftau lard certificate of death was filed why the BEFORE the burial or than' wut was issued:
(Signature of Agent of Board ofalcalth or other)
DEC - 2 1/5/2/66 19
2 ( Registrar)
PARENTS
(Signed)
ChiClan
, M. D.
(Address) Asst. Dir. Maas. Gen'l Hoap.
Date.11-21-58
6 Booch Road .Cemetery TLOUCESTER. Place of Burial or Cremation (City or Town)
DATE OF BURIAL. Nov.24.1958.
7 NAME OF
FUNERAL DIRECTOR Elefeel B. March
ADDRESS 174-Winthrop Ut. Winthrop, ass
Received and filed
November
21, 1958
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That? attended deceased from November 51958 . November 21. 1958
Wq last saw hoplive on November-2.119-58, death is said to
have occurred on the date stated above, at 1: 15p.m.
INTERVAL
BETWEEN
ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
MYOCARDIAL INFARCTION
DEATH
3DAYS
Due To
CORONARY SCLEROSIS
(b)
10YRS.
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
Yos
What tert confirmed diagnosis?
Autopsy
5 Was disease or injury in any way related to occupation of deceased ? If so, specify _..... ..
SOM-11-56-918978
301.
ONS
IFICATE
DEATH ter one each nd (c)
ot mean dying. failure. t means compli- caused
any, ise to (a), last.
contrib .- but not terminal
ter 137, requires print or use or ath on tes.
1959
(Official Designation) 1121-50
(Date of Issue of l'exmit)
BAKER MASSACHUSETTS GENERAL HOSPITAL
No.
2 FULL NAME .. MALICO Maude Mordan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
3 DATE OF
DEATH
A TRUE COPY ATTEST:
ATTESTS
Charl
RECEIVED
OF
TO
8
11 12
TILL
1
0
FEB -21959 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 STANDARD CERTIFICATE OF DEATH
OUT- OF - TOWN To be dled for burial permit with Board of Health ?: or Its Agent. a. 0 4
Registered No.
10915
f(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
2 FULL NAME
COLLIGNON, Jeffrey
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No ..
8 Vine Avenue
St
Winthrop Mass
(If nonresident, give city or town and State)
months-
Length of stay: In place of death ..
_years.
19
days. In place of residence ...
... years .......
.months ..
. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE O
DEATH
November
22
1958
(Month)
(Day)
(Year)
I HERERY CERTIFY,
That I attended deceased from
November 3
58
November 22
58
19_
4:30 a.
m.
I last saw h.
Lmalive on
November 22
58
death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) CARDIO RESPIRATORY FAILURE
INTERVAL BETWEEN ONSET AND DEATH
Due To
TUMOR OF RIGHT OCCIPITAL
(b)
LOBE OF BRAIN
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
YES
What test confirmed diagnosis?
CRANIOTOMY
5 Was disease or injury in any way related to occupation of deceased ? NG If so, specify ....
(Signed)
M. D.
(Address) NEW ENGL. CENT. H. Date Nov 22/1988
6 Hinthar Winthrop
Place of Burial or Cremation
(City or Towny
DATE OF BURIAL. November 2 % في19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and filed
NOV 25 1958
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Single
10a,'lf married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
MAMM WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
3
... Years.
8
Months
.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.
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
Douglas H Collignon
18 BIRTHPLACE OF
Niagra
Falls
FATHER (City)
(State or country)
1
n.4
19 MAIDEN NAME
OF MOTHER
Jean & mº Carthy
20 BIRTHPLACE OF
MOTIIER (City).
Winthrop
(State or country)
21 Douglas H Collignon
Informant
(Address)
quine ave wirthen
I HEREBY CERTIFY that a satisfactory standard certificate of death Wis filed with me BEFORE the burial or Transit permit was issued: Lugauchemaia 015156 (Signature of Agent of Board of Health or other) Nov. 23 1958
(Official Designation)
(Date of Issue of Permit)
X
R-301A 1
CTIONS
ERTIFICATE ving F DEATH
enter an one or each ) and (c)
s not meEN of dying. art failure, . It means or compli- ich caused
.723 any, e rise to (a), le mader- last.
as contrib. ath but mot the terminal ition given
hapter 137, 4, requires to print or cause death 00 fcates.
2
1959
{ 60M-1-58-921876
No.
The Boston Floating Hospital, 20 Ash
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(Usual place of abode)
19
to
-
newton
PARENTS
(write the word)
AGE
1
FEB - 21959 77
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.
10953
St. [give its NAME instead of street and number)
No.
2 FULL NAME
George M. NUTTING
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
120 Crest Avenue
St.
Winthrop Mass.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death .____ years.
1 months 23 days. In place of residence 10 years
... months.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
November
22
1958
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY. That Vattended deceased from September 30, 58 to November 22 1958
XXXXXXXXXXXX death is said to
have occurred on the date stated above, at 12:10 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Inanition and pulmonary
insufficiona.
Due To Carcinoma of the extrinsic (b) -
Jorym with extensive metastasis
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
Yes
What test confirmed diagnosis?
Autopsy
5 Was disease or injury in any way related to occupation of deceased ? No If so. specify Cola L. Vitação
(Signed).
Join L .- Nyers-
, M. D.
(Address) VA Hospital, Boston Date Nov. 22 19 58
6 Holyhood Comotory Brookline
Place of Burial or Cremation (City or Town)
DATE OF BURIAL November 19 58
7 NAME OF FUNERAL DIRECTORFrank Lally ADDRESS 496 Harverd St., Brookline, Mass.
Received and
M. 1.8.3 1953
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWEDDivorced
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Katherine Lawlor
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
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