USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1959 > Part 58
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SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING.
........
ORGANIZATION AND OUTFIT
SERVICE NUMBER
........
-301A 1
TIONS R ERTIFICATE
ving DEATH enter an one r each and (c)
s not mean of dying, art failure, . It means or compli- ich caused
if any, e rise to use (a), e under- sse last.
-
Cerebral Arterio- sclerosis
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
Clinical.
5 Was disease or injury in any way related to occupation of deceased If so, specify Charles Liberman
(Signed) Cheaples habe mus &M. D. (Address) Winthrop.
MT. BENEDICT1 6
BOSTONI
Place of Burial or Cremation
DATE OF BURIAL NOV 2
1959
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
ZIOWINTHROP ST WINTHROP
Received and filed. OCT 30 1959 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
FEMALE WHITE
10 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
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE20 Years
Months
Days
If under 24 hours
Hours ...... Minutes
13 Usual
Occupation :
CLER IT. SKET.
(Kind of work done during most of working life)
14 Industry
or Business:
U.S. INTERNAL REVENUE
15 Social Security No .... NONi
16 BIRTHPLACE (City)
(State or country)
MEINE
17 NAME OF
FATHER
JOHN BURKE
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
ANNE HAWKTES
20 BIRTHPLACE OF
MOTHER (City) ..
BANGOR.
(State or country)
MAINE
21 MALCOLM NICHOLS
Informant
(Address) 566 SHIRLEY ST WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Talk . Pereannex.) (Signature of Agent of Board of Health-or other) Health Officer 10/30/59
(Official Designation)
(Date of Issue of Permit)
50M-1-58-921876
PLACE OF DEATH
SUFFOLKT (County) WINTHROP (City of Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
120
To be filed for burial permit with Board of Health or its Agent.
566 SHIRLEY ST
Katherine & Burke-
2 FULL NAME.
(If deceased {s a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
566 SHIRLEY
St.
(If nonresident, give city or town and State)
Length of stay: In place of death 10 years.
months
days. In place of residence 50
years.
months ___... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
October 30 1959 (Year)
(Month)
(Day)
That I attended deceased from
4 I HEREBY CERTIFY
Oct.26
, 19:59
to
October 30
193
I last saw he Ylive on
0cx-30, 1959, death is said to
have occurred on the date stated above, at
2:55Am.
INTERVAL BETWEEN ONSET AND
DEATH 4 days
2yrs,
PARENTS
Registered No. 193
[(If death occurred in a hospital or institution,
St. [give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
NO
(Usual place of abode)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cerebral Thrombosis
Due
(b)
s contrib- th but not he terminal ition given
apter 137, 4, requires to print or cause or death 00 icates.
Date 10/30/1959
(City or Town)
ELLSWORTH
IRELAND
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 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.LA (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies of person's 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 be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made.
Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow- fis Tules of practice:[ "!
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation. the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very import- ant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
IR-301A -
THIS IS A ENT RECORD. only APPROVED nk or black itor ribbon.
UCTIONS FOR CERTIFICATE giving OF DEATH ot enter than one for each b) and (c)
our not mean of dying. heart failure. tc. It means . or compli. chich caused
us. if any. a:e rue to (*). the undet. esse last.
rath but not the terminal adition gives
Chapter 137, 954, requires a to print or cause of death on Mifcatea. P. 46. 119 & P. 114 $$ 45, AP. 38$ 6.)
12 1959
...........
PLACE OF DEATH
Suffolk (County)
Boston
(City of Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
VI-
OF - TOWN
194
To be filed for burial permit with Board of Health or Its Agent.
BAKER MEMORIAL, MASSACHUSETTS GENERAL HOSPITAL, {Of death occurred in a hospital or institution. No. . .
2 FULL NAME. Cecil B. Covington
(Cecil Boyd Covington)
(If deceased is a married, widowed or divorced woman, give also mr den name.)
(a) Residence.
No.73 Nahant Avenue
(L'sual place of abode)
St ..
Winthrop,
if so specify WAR)
Massachusetts
(If honresident, give city or town and State)
Length of stay: In place of death
years
1 months 17days. In place of residence 26 years
months ......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June
28
1959
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY.
ThatI attended deceased from
May 11
19
59.00
1959
June
28
Weast saw he Malive on
June
28
195.9. death is said to
have occurred on the date stated above, at 2:50. p.m.
10a If married.
HUSBAND of
Elsandroc Snyders
(Give til4
Line of wife in full)
(or) WIFE of
(Husband's name In full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Pulmonary Infarction
Due To (b)
Due To (c)
OTHER
Carcinoma of Bladder
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
What test confirmed diagnosis ? ...
autopsy
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
(Signed).
alloy
M. D.
(Address ASST. DIR. MASS, GEN HARJeJun. 28 19 50
6
Bellwood Cemetery
Adams , Tenn.
(City of Town)
Place of Burial or Cremation
DATE OF BURIAL
July 2,
19
59
7 NAME OF
FUNERAL DIRECTOR
J.S. Waterman & Sons
ADDRESS
Boston, Mass.
Received and filed JUL - 1 1959 19
PARENTS
18 BIRTHPLACE OF
FATHER (City).
Guthrie
(State or country)
Ky
19 MAIDEN NAME
OF MOTHER
Boyd Bell
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Tenn.
21 Mrs. Eleanor S.Covington
Informant
(Address)
73 Nahant Ave., Winthrop, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued :
W
Siphautt
CLARO Board of Health of other)
5.50,33
JAN 21; 1959
(Oficial De:20195
642925que of Permit
V.B
8 SEX Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Married
11 IF STILLBORN, enter that fact here.
12
. AGE 71 Years 7 Months 17 Days
If under 24 hours
Hours ....... Minutes
13 L'sual
Occupation :
Engineer. Retired
(Kind of work done during most of working life)
14 Industry
or Business :
Covington Co. ,Boston
15 Social Security No. 025-05-8122
Guthrie
-
16 BIRTHPLACE (City)
(State of country)
Ky
17 NAME OF
FATHER
Clarence Grant Covington
Adams
X
1
Registered No. :.
6271
give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
No
PERSONAL AND STATISTICAL PARTICULARS
INTERVAL BETWEEN ONSET AND DEATH 72hr
7 nos
A TRUE COPY ATTEST:
Charles it Mackie
City Registrar
RECEIVED
11
TO !!
ILERK
6
THRO
NOV 121959 AM
R-301A
1
Boston
(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. 08342
No. .. Peter_Bent Brigham Hospital
2 FULL NAME. Ginda Kaplan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
42 Nahant Ave.
(L'sual place of abode)
St Winthrop, Mass
(If nonresident, give city or town and State)
months ....
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Sept
7
1959
(Month)
(Day)
(Year)
WeI HEREBY CERTIFY.
ThatWettended deceased from
August 31 ... 159
to
Sept. 1.
19.59
Wel last saw h _emfive on
Sept. 1
, 19 .. 5.9, death is said to
have occurred on the date stated above, at . ..
5;20 Pm.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Massive. Pulmonary Embolis.
From Right Femorol Vein
Due To
Undifferenciated Carcinoma
(b)
Due To (c)
OTHER
SIGNIFICANT
Metastatic to Liver,
CONDITIONS
Adrenal, Lymph Nodes
Was autopsy performed ?
Yes
What test confirmed diagnosis ?.
Autopsy
5 Was disease or injury in any way related to occupation of deceased ?
If so, speck) Eugene C. Eppinger, M. D.
(Signed)
.. , M. D.
(Address) P ... Bent Brigham
Dat Sept 2,59
STARO-KONSTANTINOV
6
Place of Burial or Cremation
DATE OF BURIAL
Sept
3
1.59
7 NAME OF
FUNERAL DIRECTOR
TORF Funeral Service Inc
ADDRESS
1615 Beacon St Brookline
Received and filed
SEP_4 1959
19
Charles H. Mache
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
10a If married, widowed, or divorced
HIUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Harold
Kaplan
(Hushand's name in full)
11 IF STILLBORN, enter that fact here.
12
53.
AGE
Years
Months
Days
If under 24 hours
Hours .. Minutes
13 Usual
Occupation :
Book-keeper
(Kind of work done during most of working life)
14 Industry
or Business :
Real Estate Office
15 Social Security No.
To follow
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Nathan Braverman
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Sarah Brick
20 BIRTHPLACE OF
MOTHER (City)
(State or country )
Russia
21 Harald Kaplan
Informant
(Address)
42 Nahart ave Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death war ded Ath me BEFORE the barial or transit permit was issued:
(Signature of Agent of Board of Health or other)
64335
9/2/54
(Official Designation)
(Date of Issue of Permin)
THIS IS A NT RECORD. only PPROVED k or black er ribbon.
CTIONS OR ERTIFICATE iving F DEATH enter an one or each ) and (c)
1 not mean of dying. art failure, It means or compli. ich caused
any, , rise to use
(a). under- use
last
" contrib -- > ath but not he terminal
hapter 137, 4, requires to print or cause or death on cates. . 46,95 9 & . 114 $$ 45, P. 38 $ 6.) .
8 1959
30.023880
PLACE OF DEATH
Suffolk
(County)
CERTIFICATE OF DEATH
Registered No.
[(If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
(Braverman) -
PHYSICIAN - IMPORTANT (Was deceased a
U. S. War Veteran,
if so specify WAR)
Length of stay. In place of death years months 1 days. In place of residence 6 years
195
. PARENTS
W. Roxbury
(City or Town)
INTERVAL BETWEEN ONSET AND DEATH
A TRUE COPY ATTEST: Charis à Marakie City K.,,istrar
-
DEC - 81959 AM
COPY OF CERTIFICATE OF DEATH
CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE
TOWN OR CITY CLERK'S NO ...
1. NAME OF
A. (FIRSTI
DECEASED
(TYPE OR PRINT)
LeRoy
D. (MIDDLE)
C. (LAST)
2. DATE
OF
DEATH
10-27-59
(MONTHI (DAY)
(YEAR)
3. PLACE OF DEATH
A. COUNTY
4. USUAL RESIDENCE (WNERE DECEASED LIVED. IF INSTITUTION: RESIDENCE
B. COUNTY
Belknap
C. LENGTH OF
STAY (IN THIS PLACE)
1-2 days
C. CITY (GIVE ACTUAL TOWN OF RESIDENCE. NOT MAILING ADDRESS).
OR
TOWN
Winnisquan
D. STREET (IF RURAL. GIVE LOCATION)
ADDRESS
P.O. Box 1
E. IS RESIDENCE
ON FARM?
YES
NO
8. NAME OF HUSBAND OR WIFE (MAIDEN NAME IF WIFE)
5. SEX
Male
6. COLOR OR RACE 7.
63 High St.
MARRIED
NEVER MARRIEO
DIVORCED
WIOOWEO
9. DATE OF BIRTH
1-20-1897
10. AGE (IN YEARS
LAST BIRTHDAY)
62
IF UNDER ! YEAR MONTHS DAYS
IF UNDER 24 HRS NOURS MIN.
11A. USUAL OCCUPATION (KIND OF WORK DONE DURING NOST OF WORKING LIFE, EVEN IF RETIRED) mmachine worker, ret. Machine Shop
118. KIND OF BUSINESS OR
INOUSTRY
12. BIRTHPLACE (CITY OR TOWN, STATE
OR FOREIGN COUNTRY)
Cambridge, Mass.
13. CITIZEN OF WHAT 14. FATHER'S NAME
COUNTRY?
USA
Israel Hardy Slocum
15. MOTHER'S MAIDEN NAME
Moria Macintosh
16. WAS OECEASEO EVER IN U.S. ARMEO FORCES? 17. SOC. SEC. NO.
IYES. NO. OR UNKNOWNI ! (IF YES. GWEWAROR DATES OF SERVICE)
WW 2
--
-
18A. INFORMANT
Frederick Eugene Slocum
188. ADDRESS
10 Underhill St., Winthrop, Mass,
19. CAUSE OF DEATH (ENTER ONLY ONE CAUSE PER LINE FOR IA), (DI. AND (CI
PART I DEATH WAS CAUSED BY,
Acute cardiac failure
IMMEDIATE CAUSE (AI
CONDITIONS. IF ANY. WHICH GAVE RISE TO ABOVE CAUSE (A). STATING THE UNDER- LYING CAUSE LAST.
DUE TO (8) Pneumonia
24 Hours
MEDICAL CERTIFICATION
21A. ACCIDENT SUICIOE HOMICIDE
21B. OESCRIBE HOW INJURY OCCURREO (ENTER NATURE OF INJURY IN PART I OR PART II OF ITEM 19.)
and last saw
her him
alive on
11:00 A. m on the date stated above: and to the best of my knowledge, from the causes stated.
23A. SIGNATURE
Earl J. Gagne MD Med Ref.
(DEGREE OR TITLE)
238. ADDRESS
Laconia, N.H.
23C. DATE SIGNED
10-27-59
24A. BURIAL Z
CREMATION
ENTOMBMENT
REMOVAL
248. DATE
Oct.29, 1959
24 C. NAME OF CEMETERY OR
CREMATORY
Inthrop Com.
24D. LOCATION (CITY. TOWN. OR COUNTYI
Winthrop, Mass, Suffolk
IF ENTOMBED
24E. PLACE OF BURIAL
INAME OF CEMETERY)
LOCATION (CITY, TOWN, COUNTY) (STATE)
DATE
25. FUNERAL DIRECTOR'S SIGNATURE
Alfred B. Marsh Winthrop, Mass.
ADDRESS
COUNTERSIGNED -AGENT (CITY BD. OF NEALTN) Leonard J. Slovack HD
DATE
Oct. 27, 1957
DATE REC'D BY TOWN OR CITY CLERK
Oct. 28, 1959
CLERK'S OWN SIGNATURE
Kenneth R. Dunlap
CLERK OF
Laconia, N.H.
/ 13 1959
A true copy, Attest:
Kenneth. R. Dunlap Clerk of
Laconia, N.H ...
Dated.
10-29-59
VS 17
C.O. 18648-10-57-25M
X
21C. TIME
OF
INJURY
NONTN DAY YEAR NOUA M.
210. INJURY OCCURRED
WHILE AT
WORK
AT WORK
NOT WHILE
21E. PLACE OF INJURY (E. G., IN OR ABOUT NONE. FARM. FACTORY. STREET. OFFICE BLDG., ETC.
21F. CITY, TOWN OR LOCATION
COUNTY
STATE
22. I attended the deceased from
Death occured at
DUE TO (ČI
PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART IAI
20. WAS AUTOPSY PERFORMEO?
YES
NO
D. FULL NAME OF (IF NOT IN HOSPITAL OR INSTITUTION. GIVE STREET ADDRESS OR LOCATION)
HOSPITAL OR
INSTITUTION
A. STATE
Belknap
BEFORE ADMISSION.I
B. CITY
OR
TOWN
Laconia
Huntington
Slocum
-
HruThrop, Mass.
(STATE)
10
INTERVAL BETWEEN ONSET ANO DEATH
TOY
6
NOV 2 0 1959 40
[ R-302 1
PLACE OF DEATH
Worcester
(County)
Charlton
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
197
Charlton
(City or Town making this return)
Registered No.
§ (If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME Kate (Batson) Evans
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ...
(Usual place of abode)
Winthrop, Massachusetts
St
(If nonresident, give city or town and State)
Length of stay: In place of deathl ...... yea
7 months 9 days. In place of residence.
........... years.
months ..
.days.
MEDICAL CERTIFICATE OF DEATH
DEATH
October 29,1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,.
That I attended deceased from
7/18
19.
50
10/29
to
19.
59
I last saw
pr.
October 29
1959
death is said to
have occurred on the date stated above, at 3
a ... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Atterio Sclerotic
Heart Disease
1 yr±
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
,(write the, word)
MARRIEDWidowed
WIDOWED
or DIVORCED
10a lf married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of George H. Evans
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
86Years
9
Months.
29.
.Days
Hours ........ Minutes
13 Usual
Occupation : House wife
(Kind of work done during most of working life)
14 Industry
Retired
or
Business :
None
15 Social Security No ...
Travelers Rest
16 BIRTHPLACE (City)
(State or country)
South Carolina
17 NAME OF
FATHER
Smith Batson
18 BIRTHPLACE OF
Travelers Rest
FATHER (City)
(State or country)
South Carolina
19 MAIDEN NAME
OF MOTHER
Elizabeth Patterson
20 BIRTHPLACE OF
MOTHER (City)
Unknown North Carolina
(State or country)
21 Mark L. Ball Superintendent
Informant
(Address)
Masonie Home Charlton, Mass.
A TRUE COPY
ATTEST:
Howard M. Sargent, harlton
(Registrar of City or Town where death occurred)
DATE FILED
October ... 29
19 .... 59
X
(a) Due To (1)) 6 resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, (. 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 Due To (c)
13 1959
25M-8-56-918227
"fremation Crematory Rural Cemetary
worcesterlow
ofass.
DATE OF BURIALOctober 31
19.59
7 NAME OF
FUNERAL DIRECTOR
George Sessions sons Co.
ADDRESS/1 Pleasant St. Worcester, Mass.
Received and filed 19
(Registrar of City or Town where deceased resided)
PARENTS
Was autopsy performed?
No
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?... NO.
If so, specify.
(Signed)
MorrisDitch
M. D.
(Address)
Date.
19
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
If under 24 hours
No.
Masonic Home
(Was deceased a
U. S. War Veteran,
if so specify WAR)
1
ERK
NOV 1 31959 AM
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
198
2 FULL NAME Phoebe Richmond Doane ( Tribou )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
51 Fremont Street
St
(If nonresident, give city or town and State)
(Usual place of abode)
Length of stay: In place of death
SKyears
months.
7 days. In place of residence ...
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