USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 59
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RECEIVED
GLERK
1:1.
12
T
1
.F
6
CO
WIN
HROP NASS.
901830
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
No.
Menetich the Pleasant Street
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH Engale Local -time-
To be filed for burial permit with Board of Health or its Agent.
272
S(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)
2 FULL NAME Ellen Martha (Huby) Kitson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 35 Pico Ave St.
(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.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DiVoREAred
(write the word)
3 DATE OF
DEATH
December
19,
1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
That I attended deceased from
January 5,
19 ..
57
to
December 19,
19.60
death is said to
have occurred on the date stated above, at
8:30 p. m.
INTERVAL
BETWEEN
ONSET AND
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Acute myocardial infarction
DEATH
4 hrs
12
AGE
Years
85 4
4
If under 24 hours Hours. Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
Own home
15 Social Security No.
HuIl
16 BIRTHPLACE (City) (State or country) England
OTHER
SIGNIFICANT
CONDITIONS
Right hemiplegia
3 yrs.
Was autopsy performed ?
no
What test confirmed diagnosis ?
Clinical & laboratory
5 Was disease or injury in any way related to occupation of deceased?no If so, specify
(Signed) ThiTraungtTe. M. Traunstein, Jr. M. D.
M. D.
(PRINT OR TYPE SIGNATURE) 73 Bartlett Road
(Address) Winthrop 52, Mass.
inthrop
6 .L.inthrop Place of Burial or Cremation DATE OF BURIAL
Dec. 22
60
19
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
hinthrop
lass
ADDRESS
Received and filed
DECEMBER -21, 19 60
(Registrar)
PARENTS
17 NAME OF
FATHER
Richard Huby
18 BIRTHPLACE OF FATHER (City) (State or country) England
19 MAIDEN NAME
OF MOTHER
Martha Goodall
20 BIRTHPLACE OF MOTHER (City) (State or country) England
Informant 21 Charles Kitson (Address) 55 Pico Ave inthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Hackhs
(Signature of Agent of Board of Health or other)
(Official Designation)
HO Itec. 31/60 - (Date of Issue of Permit V.B.
RM R-301A 1
STRUCTIONS FOR AL CERTIFICATE
In giving E OF DEATH
o not enter re than one use for each .). (b) and (c)
daes not mean tade of dying, s heart failure, a, etc. It means sease, or compli- which caused
litions, if any, h gave rise ta € cause (a), ng the under- cause last.
onditions contrib- to death but nat to the terminal conditian given
:- Chapter 137, f 1954, requires ians to print or the cause or of death on certificates, and r 48, Acts of requires Physi- o print or type inder signature.
1-11-59-926662
(a)
Due To Arteriosclerotic & hypertensive
(b)
heart disease
3 yrs
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
Edmund Kitson
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
Due ToGeneralized arteriosclerosis (c)
5 yrs
Dec.20, 19 60
Date.
(City or Town)
Months.
Days
I last saw
e on
December 19,160
4
35
Registered No.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following 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 un- related 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 occu- pation, 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 impor- tant, 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. Chil- dren 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.
RECEIVED
TOWN
OF
il 12 3
in
2.
OFF
9
LERK
35 .
INTH
OP
DEC 211960 AM
. .
PLACE OF DEATH
SUFFOLK (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
[(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)
2 FULL NAME
Sykes Baby Girl
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 193 Gladstone
St.
E. Boston, Mass.
(Usual place of abode)
(If nonresident, give city or town and State)
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
December 19 1960
(Month)
(Day)
(Year)
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
4 I HEREBY CERTIFY, That I attended deceased from
Dec. 16, 1960, to Dec. 19,
19
60
10a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years ....
Months.
3
Days
If under 24 hours
Hours.
Minutes
Deform. (Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
Robert Sykes
18 BIRTHPLACE OF
FATHER (City)
(State or country)
East Boston ,Mass.
19 MAIDEN NAME
OF MOTHER
Rachel Palladino
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Rachel Sykes
21
Informant
(Address)
Same as above
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph S (Signature of Agent of Board of Health or other) Safes 12/19/60
Received and filed 19
(Registrar)
PARENTS
6
HOLY CROSS
MALden
Place of Burial br Cremation
(City or Town)
DATE OF BURIAL
Dec 19
19 60
7 NAME OF FUNERAL DIRECTOR RICHARD C. KIRBY INC ADDRESS 917 BENNINGTON ST E BOSTON
M. 1).
D ...... Thomas Staffier, M. D.
(PRINT OR TYPE SIGNATURE) 19BreedSt. E.Boston Dec. 19,60
(Address)
Menincocele
Was autopsy performed ?
No
What test confirmed diagnosis ?
None
5 Was disease or injury in any way related to occupation of deceased ? N.O .. If so, specify
D. Power
(Signed)
itions, if any, h gave rise to cause (a), ig the under- cause last.
nditions contrib- o death but not to the terminal condition given
- Chapter 137, 1954. requires ans to print or the cause of of death on ertificates, and r 48, Acts of equires Physi- print or type nder signature.
-11-59-926662
M R-301A 1
16.12 an)
STRUCTIONS FOR AL CERTIFICATE
In giving E OF DEATH not enter re than one se for each ), (b) and (c)
does not mean ode of dying, s heart failure, 2, etc. It means ease, or compli- which caused
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Anencephalus
INTERVAL
BETWEEN
ONSET AND
DEATH
Born
&
13 Usual
Occupation :
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Winthrop.
East Boston, Mass.
(Official Designation)
(Date of Issue of Permit)
I last saw h.elalive on
D.e.c ........ 18 ....
19 ... O.0, death is said to
have occurred on the date stated above, at 1: 30 .... A ... m.
Length of stay : In place of death .............. years. .. months. 3 days. In place of residence. .years.
NoWin. Community Hospital
Boston 1.4-61)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
RULES OF PRACTICE
TOWN
OF
11. 12. 1
NINA!
Iv
GLERKT
0
5
6
DEC 1 91960 PM
The fulfillment of the purpose of these laws calls for the observance of the following 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 un- related 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 occu- pation, 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 impor- tant, 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. Chil- dren 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.
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
No.
43 Court Road
The Commonwealth of Massachusetts JOSEPH D. WARD 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.
274
[(If death occurred in a hospital or institution, St. ? give its NAME instead of street and number)
John Douglas
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
43 Court Road
(a) Residence. No.
(Usual place of abode)
40
82
10
11
Length of stay: In place of death
years.
..........
.. months .............. days. In place of residence
years.
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Month)
(Day)
4 I HEREBY CERTIFY, That I attended deceased from
19
to
19
I last saw h ........ alive on
19.
.... , death is said to
have occurred on the date stated above, at
8:30 A.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Natural Causes
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
AGE
Years
Months.
.Days
11
If under 24 hours
Hours ..
Minutes
13 Usual
Occupation :
Salesman (retired)
(Kind of work done during most of working life)
14 Industry
or Business :
Produce
15 Social Security No. 28-01-4106 Winthrop
16 BIRTHPLACE (City)
(State or country)
Lass
17 NAME OF
FATHER
Alexander Douglas
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Scotland
19 MAIDEN NAME OF MOTHER Margorie Alexander
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
21 Sadie Douglas
Informant
(Address)
43 Court Road
Winthrop
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS Winthrop
Mass
Received and filed DECEMBER 21, 1960
(Registrar)
PARENTS
M. D.
Winthrop Board of Health Date 21
Dec 1,60
6
winthrop
Winthrop
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
(c)
Du
To Arterioscleratic Heart Disease
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
NO
What test confirmed diagnosis ?/
Post-Mortem judgement
5 Was disease or injury in any way related to occupation of deceased? NO.
If so, specify.
(Signed)
Arthur C. Murray
(PRINT OR TYPE SIGNATURE)
December 22 160
10a If married, widowed pedi rosshsbro
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
(a)
December 20
1960
(Year)
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDried
PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran, {if so specify WAR)
STRUCTIONS FOR AL CERTIFICATE
In giving E OF DEATH not enter re than one se for each ), (b) and (c)
does not mean ode of dying, s heart failure, , etc. It means ease, or compli- which caused
3.5.
itions, if any, h gave rise to cause (a), ig the under- cause last.
nditions contrib- o death but not to the terminal condition given
:- Chapter 137, : 1954. requires ians to print or the cause or of death on ertificates, and r 48, Acts of equires Physi- o print or type nder signature.
1-11-59-926662
(Official Designation)
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with- me BEFORE the bycial or transit permit was issued:
Jackhs.
aft (signature of Agent of Board of Health or other)
Frec. S.//6 Cm
(Date of Issue of Pernnt)
1
M R-301A X
1
Registered No.
St
(If nonresident, give city or town and State)
82
10
(b)
Presumably Coronary Occlusion
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following 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 un. related 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 occu- pation, 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 impor- tant, 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. Chil- dren 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.
RECEIVED
OF TOWN
1 ..
GLER
NIVA
5
6
THE
P. MASS.
DEC 2.11960 AM
PLACE OF DEATH
SUFFOLK
(County) WINTHROP (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
275
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) No. 26 Beacon St., Winthrop
2 FULL NAME
FRANK
THOMAS
(First Name)
(Middle Name)
(Last Name)
U. S. War Veteran,
(if so specify WAR) WW I
(If deceased is a married, widowed or divorced woman, give also maiden name.)
26 Beacon St., Winthrop
St
(Usual place of abode)
Length of stay:
In place of death.
......
.years.
.months.
days.
In place of residence.
30
.. years
months
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
December
20.
1960
(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.) Arteriosclerotic heart disease.
lla If married, widowed, or divorced FOLEY
HUSBAND of ( .....
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
If under 24 hours
13
AGE 63 Years
Months.
.......
Days
Hours ..........
.Minutes
14 Usual
Occupation :
LABORER
(Kind of work done during most of working life)
15 Industry
or Business :
GENERAL
16 Social Security No. 013-05-5693
17 BIRTHPLACE (City) CHARLESTOWN (State or country) MASS
18 NAME OF
FATHER
MICHAEL F THOMAS
19 BIRTHPLACE OF
FATHER (City)
QUEBEC
(State or country)
CANADA
20 MAIDEN NAME
OF MOTHER
ELIZABETH DENY
21 BIRTHPLACE OF
MOTHER (City)
ARLINGTON
(State or country)
MAUS
MPS VIOLET THOMAS
22
Informant/
(Address)
26 BEACON ST WINTHROP.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Machi S.
(Signature of Agent of Board of Health or other)
Htc
12/21/60
(Official Designation)
(Date of Issue of Permit) X
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. §§ 44-48.
I
M R-303 A 1
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of
of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, 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
50M-6-60-928145
(Print or Type Signature)
Date 12/20
60
19.
HOLY CROSS
7
MALDEN
Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL
DEC 23
960
8 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP-
Received and filed
Dec 21
1960
(Registrar)
PARENTS
mango M. D.
(Signed)
Michael A. Luongo, M. D.
(Address)
Boston
(Specify type of place)
Manner of
Injury
(How did injury occur ?)
Nature of
Injury
No .
While at work ?
.. Was autopsy performed ?
5 Accident, suicide, or homicide (specify)
Date and hour of injury
19
IF ACCIDENTAL, was injury causally related to the death ?
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 ?
9 SEX
MALE
10 COLOR
WHITE
(write the word)
11 SINGLE
MARRIED
WIDOWED
or DIVORCED/MIX"
(a) Residence. No.
PHYSICIAN - IMPORTANT
{ (Was deceased a
(If nonresident, give city or town and State)
6 Was diseaseor injury in any way related to occupation of deceased ?
If so, speguy
1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE JUNE 19 1914
DATE OF DISCHARGE
JULY 30
1919
RANK, RATING CORPORAL
ORGANIZATION AND OUTFIT
US ARMY
SERVICE NUMBER
1224714
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following 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) 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 poison) 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 collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. 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 spontaneouszof the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
.70
RECEIVED
NIW
DEC 211960 PM
NIM
C
301980
ORM R-304
PLACE OF DELIVERY
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)
To be filed for burial permit with Board of Health or its Agent.
Registered No.
(If death occurred in a hospital or institution, give its NAME instead of street and number)
3 DATE OF
DELIVERY Dec 22,1900
(Month )
(Day)
(Year)
4 SEX
Male ...... Female.V . Undetermined.
5 COLOR (if
determined).
6 THIS BIRTH (Check one) SingleTwin. Triplet.
7 IF MULTIPLE BIRTH, BORN : 1st ..
.. 2nd
.. 3rd
FATHER
8
FULL
NAME
David Higgins
14
MAIDEN NAME
Bridget Costigan
PRESENT NAME
.
Hissing
9
RESIDENCE, NO. 11] Hadisan St
CITY OR TOWN & Boston
STATE maso
STREET
10 COLOR OR
RACE
11 AGE AT TIME OF
THIS DELIVERY
35
(Years)
16 COLOR OR
RACE.
W .
17 AGE AT TIME OF THIS DELIVERY 33.(Years)
12 PLACE OF
BIRTH
E: Bostonas
Mass
(City or Town ,
(State or country}
18 PLACE OF BIRTH E. Boston, Mass (City or Town)
(State or country)
13 OCCUPATION Track Man MT.A
19 INFORMANT
David Higgins.
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
(a) How many children are
now living?
(b) How many children were born alive but are now dead ?
(c) How many previous fetal deaths of ANY gestation age? 1
21 LENGTH OF
PREGNANCY
40
completed
weeks
(or.
TETUS W.Oz. Grams )
23 WHEN DID FETUS DIE?
Before
Labor ..
During Labor
or Delivery.
Unknown.
25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Prolapse cord
Due To (b) Due To (c)
OTHER SIGNIFICANT
CONDITIONS
26 Holy Cross.
Malden
Place of Burial or Cremation
(City or Town) 60
DATE OF BURIAL
Dec. 23
19
27 NAME OF FUNERAL DIRECTOR
Frederick J. Nagrath 45 Waldemar Ave. E. roston
ADDRESS
Received and filed
December 23, 1960
XX
(Registrar )
I HEREBY CERTIFY that this delivery occurred on the date stated above at 2:30 Am., and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner : a. Paul Pw Hagopian M.D.
A. Paul DERHAGOPIAN M.D (PRINT OR TYPE SIGNATURE) Address: 39 CARY AV. CHELSEA Date Dec. 22 1960
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