USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1959 > Part 10
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(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 mot disabled by recognized disease, and those of persons found dead. FEB 2 7 1959 PM
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
3 DATE OF DEATH Injury Nature of Injury (Address) If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. of Death. See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF 25M-8-57-920750 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of public place ?
PLACE OF DEATH
[ R-303 A 1 Suffolk (County)
I. inthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH Hospital
To be filed for burial permit with Board of Health or its Agent.
Registered No.
No. en route to Winthrop Community/
§(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.
18 Townsend Street
St
1. inthron,
La.s.s ..
(Usual place of abode)
Length of stay: In place of death ..... years.
months.
........... days. In place of residence
..... years ....
-monthdays.
2
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
FEMALE
10 COLOR OR RACE
WHITE
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
SINGLE
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.
13
AGE ...
Years
Months ...
„Days
If under 24 hours
......
.. Hours .......... Minutes
14 Usual
Occupation :
(Kind of work done during most of working life)
15 Industry
or Business :
NONE
16 Social Security No. MINE
WINTHROP
MASS
17 BIRTHPLACE (City)
(State or country)
18 NAME OF
FATHER
FRANCIS P GILFOYLE
19 BIRTHPLACE OF
BOSTON
FATHER (City)
(State or country)
MASS
20 MAIDEN NAME
OF MOTHER
FLORENCE P. FITZPATRICK
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
FRANCIS P GUILFOYLE
22
Informant
(Address)
IS TOI NESEND ST WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was, filed with me BEFORE the burial or transit permit was issued:
8 NAME OF
FUNERAL DIRECTOR
Manue VF 1 July
ADDRESS WINTHROP
Received and filed MAR 2 1959
19.
(Registrar)
PARENTS
6 Was disease or injury in any way related to occupation of deceased ?.
If so, specify
Leonard action
M. D.
(Signed)
25 Shattuck St., Date 2/27
1959
WINTHROP
WINTHROP
(City or Town)
Place of Burial, or Cremation.
DATE OF BURIAL
MARCH 2
,50
JVCi
2 FULL NAME
KAREN GILMOVIE
(If deceased is a married, widowed or divorced woman, give also maiden name.)
MEDICAL CERTIFICATE OF DEATH
February
1.959
(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.) PNEUMONITIS
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
Manner of
(Specify type of place)
(How did injury occur ?)
While at work?
Was autopsy performed? NO
CHELSEA
(Signature of Agefit of Board of Health or other)
Health Officer
3/1/59
(Official Designation)
(Date of Issue of Permit)
(If nonresident, give city or town and State)
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 deccased, 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 belicf, 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 imine- 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. as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931. No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the conunonwealth 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., as amended.
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 cheinical, 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. .. - Gencral Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4. Acts of 1945.
The medical examiner certifies the cause and manner of death to the best of his knowledge and belief.
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 dufing'a last.illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deathsonly 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
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway accident.""Pistol shot wound of the chest with associated hemorrhage, hom- icidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, sperify. If investigation shows the death to have been due to disease, specify: (1)Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)''
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT.
SERVICE NUMBER
X PLACE OF DEATH
SUFFOLK
(County)
BOSTON
(Clty or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT- CD To be filed for burial permit with Board of Health of Its been . 116.22
2 FULL NAME
GEORGE KOCH
(If deceased Is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
52 A Trident st.
St.
WINTHROP, MASS
(If nonresident, give city or town and State)
Length of stay: In place of death ...
.... years
months.9.
days. In place of residence
15 years ..
.months ......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATII
JANUARY
2
1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
That Pattended deceased from
Dec. 24,, 19 58,
... Jan ... 2,
19.59
Wp last saw am alive on
Jan ... 2,
-, 19 58, death is said to
have occurred on the date stated above, at
6:25P. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Buoncho pneumonia acute
right
Due To
Diabetes Mellitus
(b)
Due To (c)
Myocardial infarct, heAled postern
3 months work. mosthey
Was autopsy performed?
yes
What test confirmed diagnosis ?.
autopsy & clinical
S Was disease or injury In any way related to occupation of deceased ?
If so, specify
(Signed)
(Address) Anat. Dir. Mars. Gen'l Hasp.
Date
1/3/
. M. D. 1,59
6 Winthrop Place of Burial or Cremation DATE OF BURIAL
Winthrop
(City or Town)
Jan. 5
19 59
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynol
ADDRESS
Winthrop
Mass
JANªF 2 1959
Received and filed
JAN 1 2 1950
fart
91 (Registrar)
PARENTS
17 NAME OF
FATIIER
Godfrey Koch
18 BIRTHPLACE OF
Providence
FATHER (City)
(State or country)
R.I.
19 MAIDEN NAME
OF MOTIIER
Sarah L
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
R. I.
Providence
21
Informant
Iva Koch
(Address) 52A Trident Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was)filed with me BEFORE the burial or transit permit was issued : I Meade
(Signature of Agent of Board of Health or other)
153
1- 5-59
(Official Designation)
(Date of Issue of Permit)
RUCTIONS FOR CERTIFICATE
giving OF DEATH not enter than one for each (b) and (c)
does not mean of dying, heart failure. str. It means Y, or compli- wekick caused
us, if any. ave rise to can't
(a). the under- last.
DECLINED BY MEDICAL EXAMINER
ons contrib. frath but not the terminal adition given
Chapter 137, 954, requires s to print or cause desth on tifcates.
31 1959
GOX-1-68-921876
No.
MASSACHUSETTS GENERAL HOSPITAL
[(If death occurred in a hospital or institution,
St. [give ita NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Usual place of abode)
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
of DIVORCED
Married
10a If married, widowed, or divorcewa Holmes 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
78
11
AGE
Years
Months
7
Days
If under 24 hours
-
_Hours ....... Minutes
13 Usual
Occupation :
Machinist
(Kind of work done during most of working life)
14 Industry
or Business:
Boston Elevated
15 Social Security No ... None
16 BIRTHPLACE (City).
(State or country)
R.I.
Providence
OTHER
SIGNIFICANT
CONDITIONS
Dietetic glindevalasmarts
years
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
INTERVAL BETWEEN ONSET AND DEATH 5 days
unknown
MR-301A 1
Registered No.
CVTDAATA
A TRUE COPY ATTEST: Charles it Mackie City Registrar
TOW.
6
MAR 311959 AM
SOM-3-57-920345
7 NAME OF
M. LINEHAN
ADDRESS 19 CHAMBERS STI BOSTON
Received and filed ..
JAN 1 3 1959 ... 19
Charles 2 Tonn
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
SINGLE
10a If married, widowed, or divorced
HUSBAND of
(Give malden name of wife in full)
(or) WIFE of
(Ilushand's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years
Months 2 Days
If under 24 hours
.......
Ilours
Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTIIPLACE (City).
(State or country)
Boston MASS
17 NAME OF
FATIIER
JAMES THOMPSON
18 BIRTIIPLACE OF
FATHER (City)
E. Boston.
(State or country)
MASS.
19 MAIDEN NAME
OF MOTHER
MILDRED HURLEY
20 BIRTIIPLACE OF
MEDFORD,
MOTHER (City) ...
(State or country)
MASS.
21 Boston Lying in Hospital
(Address)20) Longwade Avec, Baston MAS. I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the hurial nr transit permit was issued: WAKame
(Signature of Agent of Board of Health or other)
845
1-9-19
(Official Designation)
(Date of Issue of Permit)
X
MR-301A I
PLACE OF DEATH
X SUFFOLK (County) Boston (City cr Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
To be filled for burlal permit with Board of Health or it's Agent. 00245
28
Boston Lying-IN Hospital No. BABY Boy THOMPSON TWIN 2
[(If death occurred in a hospital or Institution, St. (giyy its NAME instead of street and number)
PHYSICIAN -- IMPORTANT
(Was deceased a U. S. War Veteran. ( if so specify WAR)
52, MASS.
(If nonresident, give city or town and State)
months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
JAN.
5
1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
JAN. 3. 1954
tn
JAN
5
, 1959
I last naw h' _._ alive on
JAN.5, 1959, death is said to
have occurred on the date stated above, at 9.48 A. m.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
HYALINE
MEMBRANE
Due To
SubARAch Noid KEMorphAGE
- (b)
Due To (c)
OTHER
SIGNIFICANT
PREMaturity
CONDITIONS
YES
Wa's autopsy performed?
What test confirmed diagnosis ?..
5 Was disease or injury in any way related to occupation of deceased ? No
If so, specify
(Signed)&
RAZ. Longwood Ave
Date Jan. 5 1909
, M. D.
6
ST. MICHAELS CEM/ BOSTON
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
JAN. 10,
1958
PARENTS
Registered No.
2 FULL NAME
( If deceased in a married, widowed or divorced woman, give also maiden name.) 30 CRYSTAL COVE AVE S. WINTHROP
(a) Residence. No.
TRUCTIONS FOR L CERTIFICATE
I giving OF DEATH
aot enter than one for each (b) and (c)
does not mean e of dring. heart failure. str. It means se, or compi- which
ranted 760.5
ORS, if any, gave rise to (a), the under- cause last.
tions contrib. . death but not the terminal condition given
Chapter 137, 1954, requires Las to print or 10 cause or of death ea rtificates.
31 1959
(Usual place nf abnde)
Length of stay: In place of death years months days. In place of residence years
CVTDAATA
A TRUE COPY ATTEST: Charles it Mackie City Registrar
TOR
-1.1% .
0
MAR 3 11959 AM
RM R-301A 1
ISTRUCTIONS FOR CAR CERTIFICATE
In giving LE OF DEATH
o not enter ore than one usa for each 1), (b) and (c)
is does not mean mode of dying. as heart failure. 14, etc. It means seave, or compli- which carted 760.3
a'itions, if any, It gave rise to (.). eng the
under- cause last.
Due To (c)
OTIIER
SIGNIFICANT
PREMaturity
CONDITIONS
Was autopsy performed?
YES
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? No If so, specify
(Signed) MancandIca , M. D. RAZd. LangwonD Ave Date Jan. 5 1909
6 ST. MICHAELS CEMI/ BOSTON Place of Burial or Cremation (City or Town)
DATE OF BURIAL
JAN. 10,
1958
7 NAME OF
IM. LINEHAN
FUNERAL DIRECTOR
ADDRESS 19 CHAMBERS STI BOSTON
Received and filed JAN 1 3 1959 .19
Charles & Imack
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
IO SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
SINGLE
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Ilusband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years
Months 2 Days
If under 24 hours
... Ilours
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)
BOSTON MASS.
17 NAME OF
FATHER
JAMES THOMPSON
18 BIRTIIPLACE OF
FATHER (City)
(State or country)
E. Boston.
MASS.
19 MAIDEN NAME
OF MOTHER
MILDRED HURLEY
20 BIRTIIPLACE OF
MEDFORD,
MOTHER (City).
(State or country)
MASS.
21 Boston Lying IN Hospital
Informar
(Address)a) Longwado Que, Baston Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: WAKame
(Signature of Agent of Board of Health or other)
845
1-9-19
(Official Designation)
(Date of Issue of Permit)
X
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
JAN
5
1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
JAN. 3. 1954.
to
AN.
5
, 1959
I last naw h' .... alive on
JAN.5, 1959, death is said to
have occurred on the date stated above, at 9 48 A. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
HYALINE
MEMBRANE
MAISFASE
Due To
SubARAch Noid KEMorphAGE
-
(b) ..
-
PLACE OF DEATH
X SUFFOLK (County) Boston (City cr Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
ET
28
To be filed for burial permit with Board of Health or its Agent. 10245
Registered No.
f(If death occurred in a hospital or institution,
St. (giy, its NAME instead of street and number)
PHYSICIAN - IMPORTANT
1
(Was deceased a
U. S. War Veteran,
( if so specify WAR).
(If deceased is a married, widowed or divorced woman, give also maiden name.) 30 CRYSTAL COVE AUE. S. WINTHROP, 52, MASS
(a) Residence. No. (Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death ....... years_ ....... months days. In place of residence years ... months days.
Boston Lying-IN Hospital
2 FULL NAME- BABY
THOMPSON IWIN
2
That I attended deceased from
INTERVAL BETWEEN ONSET AND DEATH
PARENTS
SOM-5-57-920345
R 31 1959
(nditions contrib -- > to death but not " to the terminal a condition giura
Te :- Chapter 137, t of 1954, requires Jcisns to print or tha cause of 's of death en cartidcates.
C.V.T.DAATA
A TRUE COPY ATTEST: Charles it Mackie City Registrar
x
5
MAR 31 1959 AM
RM R-301A 1
KSTRUCTICHIS FOR CAL CERTIFICATE
In giving JE OF DEATH
lo not enter pro than one use for each B), (b) and (c)
is does not mean mode of dying, as heart failure. in, etc. It means brass, or compli- > 177
Titions, i/ any. gave rise to (a). 's the under- last.
taditions contrib .- ito death but not to the terminal condition giorn
0: Chapter 137, lof 1954, requires clana to print ar e the cause or lı of death on t certificates.
R 31 1959
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 filed for buriat permit with Board of HealthDE or tta 00526
Registered No.
f(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and numher) PHYSICIAN - IMPORTANT -
2 FULL NAME
EVERETT WORTHLEY
(ff deceased is a married, widowed or divorced woman, give also maiden name.)
142 PLEASANT STREET
St
WINTHROP, MASS.
(If nonresident, give city or town and State)
Length of stay: In place of death.
.. years.
. months
days. In place of residence
7.5years.
months .... .... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Divorced
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
hat known
(Ilusband's name in full)
ti IF STILLBORN, enter that fact here.
12
AGE
75 Years 2 Months 12 Days
If under 24 hours
Hours ....... Minutes
13 Usual
Brech Retired
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
Que Johnson Boston
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