Town of Winthrop : Record of Deaths 1962, Part 1

Author: Winthrop (Mass.)
Publication date: 1962
Publisher:
Number of Pages: 510


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 1


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Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49


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X


PLACE OF DEATH


Suffolk (County)


Winthrop


(City or Town)


No. 80 Upland 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.


1


[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


2 FULL NAME


Elmer .... Stuart Lipsett


(First Name)


(Middle Name)


(Last Name)


[ (Was deceased a { U. S. War Veteran, lif so specify WAR) W.W.1


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No. !


80 Upland .Road


(Usual place of abode)


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


male


9 COLOR


white


10 SINGLE


(write the word)


MARRIED married


WIDOWED


or DIVORCED


4 I HEREBY CERTIFY,


That I attended deceased from


19


I last saw hj.malive on


19 ............ , death is said to


have occurred on the date stated above, at


11:20 Am.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Natural Causes


(a)


INTERVAL


BETWEEN


ONSET AND


DEATH


sudden


Due To


(b) Presumably Coronary Occlusion


Due To


(c) Arteriosclerotic Heart Disease


OTHER


SIGNIFICANT


CONDITIONS


Hypertension


10 yrs 10 yrs


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 .......


0. Arthur C. Murray,


Arthur C. Murray


(PRINT OB TYPE SIGNATURE)


Winthrop Board of Health at


2 Jan 19 62


Winthrop Cemetery


Winthrop Mass MOTHER (City)


6 Place of Burial or Cremation (City or Town)


DATE OF BURIAL


January 4,1962


19


7 NAME OF


FUNERAL DIRECTOR


alfred B. March


ADDRESS


174 Winthrop St. Winthrop,


Received and filed 19


(Registrar)


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Nova Scotia


19 MAIDEN NAME


OF MOTHER


Mabel Phillips


20 BIRTHPLACE OF


(State or country) Maine


Mr.s ........ Elmer ..... S ........ Lipsett


21 Informant (Address) 80 Upland Road Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit, permit was issued:


Mass.


Kach E Surranni


(Signature of Agent of Board of Health or other)


Heath Office


1/3/62


(Official Designationy (Date of Issue of Permit)


INSTRUCTIONS FOR ¿DICAL CERTIFICATE


In giving USE OF DEATH do not enter more than one cause for each E (a), (b) and (c)


This does not mean mode of dying, h as heart failure, senia, etc. It means disease, or compli- ons which caused th.


Conditions, if any, which gave rise to bove cause (a), tating the under- ying cause last.


Conditions contrib- ig to death but not ted to the terminal ase condition given a).


Note :- Chapter 137, cts of 1954, requires nysicians to print or pe the cause or uses of death on ath certificates, and lapter 48, Acts of 59, requires Physi- ans to print or type ime under signature.


M-6-60-928145 T


11 IF STILLBORN, enter that fact here.


12


AGE .. 65


1.0Months2.6 .... Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Advertising agent


(Kind of work done during most of working life)


14 Industry


or Business :


paper ..... Mfg .Co ..


15 Social Security No.


028-03-2352


16 BIRTHPLACE (City)


(State or country)


Mass


Melrose


19


to.


10a If married, widowed, or divorced


HUSBAND of


.Hva .... Frances ...... Barrett


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


40


(If nonresident, give city or town and State)


16


3 DATE OF


DEATH


January


1


1962


(Month)


(Day)


(Year)


St.


Registered No.


ORM R-301A 1


17 NAME OF


FATHER


Andrew Lipsett


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE. n-7-1917


DATE OF DISCHARGE


7-1-19,9


RANK, RATING


SIE 1ST Class


ORGANIZATION AND OUTFIT


1. 407-8,7


bilization : Devar


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.


X


PLACE OF DEATH


Suffolk (County)


SENSIE


Winthrop


(City or Town)


No. 17 Irvin Street


The Commomuralth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


Dr King To be filed for burial permit with Board of Health or its Agent.


2


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, lif so specify WAR)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


17 Irwin Street


St.


(If nonresident, give city or town and State)


Length of stay: In place of death. .... .. . .years. 2 months days. In place of residence .years. months .days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


JAN


DEATH


(Month)


(Day)


1


1962


(Year)


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED Widow


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


Alfred E Whitehead


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


76


Years ....


4


Months.


0


Days


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


None


15 Social Security No.


County Cork


16 BIRTHPLACE (City)


(State or country)


Ireland


17 NAME OF


FATHER


Butler


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Ireland


19 MAIDEN NAME


OF MOTHER


Mary His Unable to obtain.


20 BIRTHPLACE OF MOTHER (City) (State or country) Ireland


21 Edna Joseph


Informant (Address) 135 Ocean Ct. Lynn Mass


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit. was issued:


(Signature of Agent of Board of Health or other)


62


(Official Designation)


(Date of Issue of Permit)


-


1


INSTRUCTIONS FOR DICAL CERTIFICATE


In giving JSE OF DEATH do not enter more than one cause for each (a), (b) and (c)


his does not mean mode of dying, as heart failure, nia, etc. It means disease, or compli- which caused ns 4.


ditions, if any, hich gave rise to ove cause (a), Iting the under- ing cause last.


Conditions contrib- g to death but not ed to the terminal 'se condition given 1).


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) Ingran 2. 5mg M. D. MYRON N.KINGM.D (PRINT OR TYPE SIGNATURE)


(Address)24 FLETTJAN: 5 WINY Hun Date.


inthrop


Place of Burial or Cremation


DATE OF BURIAL


Jan.


14


19.


7 NAME OF


FUNERAL DIRECTOR


Howard S Reynolds


ADDRESS Winthrop Mass.


Received and filed


19


(Registrar)


INTERVAL BETWEEN ONSET AND DEATH


DEATH WAS CAUSED BY : IMMEDIATE CAUSE _ (a) artère balenticHeart Disease with congestive facture


(b)


Due To GENERAL ARTERIOSCLEROSIS


375.


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


CIRROSIS OF LIVER


7 YRS-


6 winthrop


(City, or Town) 62


PARENTS


1/2


PERSONAL AND STATISTICAL PARTICULARS


37


Mary K (Butler) Whitehead


2 FULL NAME


(a) Residence. No. (Usual place of abode)


4 I HEREBY


CERTIFY,


That I attended deceased from


1962


JUNE 28


1902


to


JAN


1


I last saw hat Ralive on


12/24


, 1961


death is said to


have occurred on the date stated above, at .


123- A


.m.


2 YRS. AGE


ORM R-301A 1


›te :- Chapter 137, : of 1954. requires sicians to print or the cause or .es of death on h certificates, and pter 48, Acts of , requires Physi- s to print or type e under signature.


)OM-6-59-925686 7


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.


FORM R-303


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


§§ 44-48.


50M-3-61-930213


1


SUFFOLK (County)


WINTHROP


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE 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.


3


400 Revere Street, Winthrop


PHYSICIAN - IMPORTANT


[ ( Was deceased a


(First Name) (Middle Name) (Last Name)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


400 Revere Street, Winthrop


St.


(If nonresident, give city or town and State)


25. .. years .. months .. ...... ... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


9 SEX Female


10 COLOR


white


11 CITIZEN


OF U.S.


YES


NO


12 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN


4I 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.


(or) WIFE of


George (Give sharpe


wife in full)


(Husband's name in full)


13 DATE OF BIRTH


May


19. 1891


14 ÅG 70 .Years. 7 Months ... Days


If under 24 hours .Hours .Minutes


...


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, of


(Specify type of place)


(How did injury occur ?)


While at work ? Was autopsy performed


6 Was disease or injury in any way related to occupationof deceased ?


If so, specify


(Signed) Michael A. Luongo


(Print or Type


Vame)


1/2


19 ,62


(Address) Winthrop


Date Winthrop


7 Place of Burial, or Cremation.


(City or Town)


DATE OF BURIAL


January 5, 1962


8 NAME OF


FUNERAL DIRECTOR


Arthur J. OMaley


ADDRESS Winthrop, Mass


Received and filed


1 1.00 19


A TRUE COPY ATTEST:


(Registrar)


PARENTS


21 MAIDEN NAME


OF MOTHER


Margaret Maxwell


Cambridge


22 BIRTHPLACE OF MOTHER (City) (State or country) Mass


23 William Donovan ·


Informant (Address) 230 Pleasant St Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death . with me BETA burial or transit permit was issued:


Mistimun of Agent of


1/4/ 62.


(Official Des.geldi


1


2 FULL NAME 3 DATE OF DEATH Manner of Injury Nature of Injury If deceased was a U. S. War Veteran, (I.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. public place ?


OR TYPE THE CAUSE OR CAUSES OF DEATH ON DEATH CERTIFICATES.


N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of -


§(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) No. MARGARET I. SHARPE


(a) Residence. No. (L'sual place of abode)


Length of stay : In place of death. .. years ... . ..... .months ..


January


2,


1962


(Month)


(Day)


(Year)


12a If married, widowed, or divorced HUSBAND of


15 Usual Occupation : ...


waitress


(Kindof work done during most of working life)


16 Industry Business.


Restaurant


curit


No.


030-22-6753


18 NRTHPLACE (City)


(State or country)


Cambridge Mass


19 NAME OF


FATHER


John Mc Court


20 BIRTHPLACE OF


FATHER (City)


(State or country)


Cambridge


Mass


0


M. D.


Boston


PLACE OF DEATH


Registered No.


U. S. War Veteran,


[if so specify WAR)


No


days . In place of residence.


5 Accident, suicide, or homicide (specify)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


OF


TOK:


1.1.17


3


RULES OF PRACTICE


6


The fulfillment of the purpose of these laws calls for the observance of the following rules 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 JANersoAs98pofithough 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 spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"


X


PLACE OF DEATH


(County)


inthron


(City or Town)


No. .....


interce Comunitat


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.


4


[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME alert (First Name) (Middle Name) (Last Name)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


3" Frinonter it.


St. -......


03:on


(If nonresident, give city or town and-State)


months.


days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


male


9 COLOR


white


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCEMarried


4 I HEREBY CERTIFY,


Dec 2, 1961


19


That I attended deceased from


to January 2


1962


I last saw h alive on


January L, 1962, death is said to


have occurred on the date stated above, at


6 .: 45 P.m.


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


Pulmonary Embolism


(a)


INTERVAL BETWEEN ONSET AND DEATH


Due To


(b)


Carcinoma of bowel


Due To


(c)


Post-operative)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


What test confirmed diagnosis?


5 Was disease or injury in any way related to occupation of deceased?


If so, specify


(Signed Nathaniel P. Danoff M. D


(Address)32 Prin neeton St. E.B Date Jan, 2 1962


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL Jan. 6


19


7 NAME OF


FUNERAL DIRECTOR


Frederick J. Larrath


ADDRESS 325 Chelsea St. E. - oston


Received and filed


in 19


(Registrar)


PARENTS


19 MAIDEN NAME


OF MOTHER


Olevia Smith


20 BIRTHPLACE OF MOTHER (City) (State or country)


Nova Scotia


21 Informant


Amaryllis Swimm


(Address)


37 Princeton St. E. Foston


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit) permit was issued: Traviny & Pereanus (Signature of Agent of Board of Health or other) Health Receive 1/3/62


(Official Designation)


(Date of Issue of Permit)


INSTRUCTIONS FOR ICAL CERTIFICATE


In giving SE OF DEATH do not enter more than one ause for each (a), (b) and (c)


is does not mean mode of dying, as heart failure, nia, etc. It means lisease, or compli- s which caused .


ditions, if any, ich gave rise to ve cause (a), 'ing the under- cause last.


Conditions contrib- to death but not d to the terminal e condition given ).


ote :- Chapter 137, s of 1954, requires 'sicians to print or : the cause or ses of death on th certificates, and pter 48, Acts of ), requires Physi- is to print or type le under signature.


6-60-928145


11 IF STILLBORN, enter that fact here.


12


AGE 70 Years


Months ...


.Days


If under 24 hours


Hours ...


.. Minutes


13 Usual


Occupation :


foreman


(Kind of work done during most of working life)


14 Industry


or Business :


retired


15 Social Security No.


011-01-3617


Clarks Harhon


16 BIRTHPLACE (City)


(State or country)


Nova Scotia


17 NAME OF


FATHER


Nathaniel Swimm


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Nova Scotia


(PRINT OR TYPE SIGNATURE)


10a If married, widowed, or divorced


Amaryllis I Nickerson


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


3 DATE OF


DEATH


....


(Month)


(Day)


1962


(Year)


((Was deceased a U. S. War Veteran,


{if so specify WAR) WWW 1


(a) Residence. No. (Usual place of abode)


Length of stay: In place of death.


.years


months


31


.days.


In place of residence


years.


Registered No.


J


82-8im


RM R-301A 1


Clarks Harror


Nova Scotia


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE 7/30/18


DATE OF DISCHARGE


8/28/19


RANK, RATING


ORGANIZATION AND OUTFIT


Qtrmaster Corps


U.S. Army


SERVICE NUMBER 4306787


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


OFFICE OF


11 12. 1


V


MIN


is


CLERK


5


6


'11


THROF


JAN 3 1962 PM


FORM R-302


WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD


X


PLACE OF DEATH


Essex


(County)


1


Danvers.


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


Danvers


(City or Town making this retu.


5


Danvers State Hospital,


S (If death occurred in a hospital or institution. Hathorne .. St. ( give its NAME instead of street and number)


Mary u Black (Brooks )


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No. 137 Bowdoin Street ( Usual place of abode)


........


St


Winthrop.


Mass


(If nonresident, give city or town and State)


Length of stay: In place of death


2 ears. 4 months .. ZOdays. In place of residence .......... years ...... .. months .......... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


(Month)


(Day)


That I


attended deceased from


August 20, 19


59.


to ..


January ........ 5


19


.62


1 last saw


h.o.klive on


Jan.


19 .. 62


death is said to


have occurred on the date stated above, at


INTERVAL BETWEEN ONSET AND DEATH


years


12


AGE.


1.0Months ...


2.9Days


If under 24 hours


Hours ........ Minutes


13 Usual


Occupation:


Domestic


(Kind of work done during most of working life)


14 Industry or Business :


15 Social Security No.


Unknown


OTHER


SIGNIFICANT




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