USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 1
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1
THOMAS GROOM & CO.INC. STATIONERS. AND ACCOUNT BOOK MANUFACTURERS 105 State Street, BOSTON.
To duplicate this Book send number V-28967
Digitized by the Internet Archive in 2016 with funding from Boston Public Library
https://archive.org/details/townofwinthropre 1963wint
RM R-303
d for burial permit Board of Health r its Agent.
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
X 1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
mynn 2-7-63
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
8-28767
(City or Town making this return)
Registered No.
No. 17 Hillside Ave. .....
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
DAVID
E.
DOMEY
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
(a) Residence. No.
72 Autumn St., Lynn
(Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay:
In place of death ............ years.
months
1
days. In place of residence
SI
.years
11
months.
2
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
January
1,
19.63
(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.) Acute myocardial infarction.
9 SEX
M
10 COLOR
white
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word )
.
married
12 If married, widowed, or divorced
HUSBAND of
Louise
Webber
(or) WIFE of
(Husband's name in full)
13 DATE OF BIRTH
Jan. 29
1911
14 AG 51 Years. VI
........ Months ....
.Days
If under 24 hours .. Hours Minutes
15 Usual
Occupation
Track
Driver
(Kind Ofwork done during most of working life)
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or public place ?
Manner of
Injury
(How did injury occur ?)
Nature of Injury
While at work? Was autopsy performed?
No
6 Was disease or injury in any way related to occupation of deceased?
......
(Signed)
M. D.
Michael AL
NOPEOS M.D.
(Print or Type ame)
(Address) Maas . Date 1/1
1963
ST. Marys
Lynn
Place of Burial, os Cremation.
(City or Town)
DATE OF BURIAL Jan 4
1963
8 NAME OF
Charles A. Wall
ADDRESS 103 Johnson ST. Linn
Received and filed
JAN 2 1963
19
A TRUE COPY ATTEST:
(Registrar)
18
18 BIRTHPLACE (City)
(State or country)
Mass.
19 NAME OF
FATHER
Frank Domey
20 BIRTHPLACE OF
FATHER (City)
ST. Albans
(State or country)
Vermont
21 MAIDEN NAME
OF MOTHER
Catherine Callahan
22 BIRTHPLACE OF
MOTHER (City)
Co. Limerick
(State or country)
Ireland
David A. Domey
23
Informant
(Address)
29 Saunders Rd, Lynn
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Telf & E. Percance
Realita
(Signature of Agent of Board of Healthfor other)
Effect
1/7/67
(Official Designation)
(Date of Issue of Perunit)
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.
50M-9-61-931348
7
Boston,
PARENTS
16 Industry or Business.
Drspatch Co.
17 Social Security No.
206 05
8491
Lynn
(Specify type of place)
IF ACCIDENTAL, was injury causally related to the death? Where did Injury occur ?
(Give maiden name of wife in full)
5 Accident, suicide, or homicide (specify)
Date and hour of injury
19
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
-
-
1
;
DATE OF DISCHARGE
1
1
RANK, RATING
ORGANIZATION AND OUTFIT
:
SERVICE NUMBER
JAN -21963 PM
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 spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
ORM R-301
I for buriaf permit oard of Health its Agent. TRUCTIONS FOR L CERTIFICATE
OR TYPE OR CAUSES DEATH
not enter e than one e for each (b) and (c)
does not mean de of dying, heart failure, ,etc. It means ase, or compli- which caused
tions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not to the terminal condition given
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
2
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME Dulcie Mahoney
(If deceased is a married, widowed or divorced woman, give also maiden name.)
11 Bowed 1 0 51
(a) Residence. No ..
(Usual place of abode)
136 Cottage Park Road
St
(If nonresident, give city or town and State)
... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
January 6, 1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Lune
19.5/
to
6 Jan
19
63
I dast saw heralive on
6
Lara, 1963, death is said to
have occurred on the date stated above, at
6:45 P.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Coronary Occlusion
INTERVAL
BETWEEN
ONSET AND
DEATH
36 hrs.
Dy Arteriosclerotic Heart Disease
10 yrs
Cy Generalized Arteriosclerosis
10yrs
OTHER
SIGNIFICANT Cerebro Vascular Incident
CONDITIONS
with hemiplegia
1 Yr.
Was autopsy performed?
no
What test confirmed diagnosis ?
clinical observation
5 Was disease or injury in any way related to occupation of deceased ? no If so, specify
(Signatures Arthur C. Murray ArthurC .Murray
M. D.
(Address)
Minchop
Date ? Jan 19 63
6
Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
January 9
19.
63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS Winthrop Mass.
Received and filed
JAN 8 1963
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWER
DIVORCWidowed
UNKNOWN
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
James F. Mahoney
(or) WIFE of.
(Husband's name in full)
12
AGE .. 7.2 Years.
Months.
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation
Housewife
(Kind of work done during most working life)
14 Industry
or Business:
Own Home
15 Social Security No ....
16 BIRTHPLACE (City)
(State or country)
Nottingham
England
17 NAME OF
FATHER
Frederick Plumbley
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Ann Smith
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
England
21 Informant
Barbara .Cox
( Address)
136 Cottage Park Road, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Ferran
.......
{Signature of Agent of Board of Health or other) Health indicar
Velica.1 8 1965
(Registrar)| (Official Designation)
(Date of Issue of Permit)
A TRUE COPY AT ATTEST:
62-932382
1
No ......
MLKLOWSE NUR ! 39 Grovers Ave
Registered No.
(Was deceased a
U. S. War Veteran,
(if so specify WAR) ..... NO
Length of stay: In place of death .......... year ... Q.
.. months ......
.. days. In place of residenc2.5.
(a)
-
PARENTS
(Print of Type Name)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
JAN - 81963 AM
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-301
led for burial permit Board of Health or its Agent. NSTRUCTIONS FOR CAL CERTIFICATE
NT OR TYPE SE OR CAUSES OF DEATH do not enter more than one use for each (a), (b) and (c)
is does not mean mode of dying, as heart failure, nia, etc. It means disease, or compli- s which caused .
nditions, if any, ich gave rise to ve cause (a), ting the under- cause last. ng
Conditions contrib- to death but not d to the terminal se condition given ).
X 1
PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No. 3
No.
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
26 Cliff Avenue, Winthrofee: McDonald WINTHROP COMMUNITY HOSPITAL
(a) Residence. No ..
(Usual place of abode)
Length of stay : In place of death .......... years .......... months.
3
days. In place of resident
years.
.. months.
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED widowed
WIDOWED
DIVORCED
UNKNOWN
femalelwhite
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Lewis Seaborn Leitch
(Husband's name in full)
12
3 WKS AGE .. 7 .. ]. Years .. & Months ........... Days
If under 24 hours
Hours.
Minutes
13 Usual
housework
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :.
own .... home
15 Social Security No ...
029-05-6958-A
16 BIRTHPLACE (City).DOS con (State or country ) Massachusetts
17 NAME OF FATHER James McDon 1d
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
unable to obtain
20 BIRTHPLACE OF MOTHER (City). (State or country) England
21 Informant
Mrs ...... Robert .. V.„Atcherley
(Address)
164 Woodside Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
Rueph E. Sivanne (B)
(Signature of Agent of Board of Health or other) Health Officer 1/11/63
(Registrar) || (Official Designation),
(Date of Issue of Permit)
2-62-932382
A TRUE C
A TRUE COPY ATTEST: PY ATTEST:
Winthrop , Mass.
6
Winthrop Cemetery,
Place of Burial or Cremation
(City or Town)
1963
DATE OF BURIAL January 11.
7 NAME OF
FUNERAL DIRECTOR
alfred B. March
.19
ADDRESS
174 Winthrop St. Winthrop, Maswas filed with me BEFORE the burial or transit permit was issued:
Received and filed JAN-11-1953 19
INTERVAL BETWEEN ONSET ANO DEATH
(a) CARDIAC FAILURE
Due To (b)
CORONARY THROMBOSIS
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
NO
What test confirmed diagnosis ?
ELECTROCARDIOGRAM
5 Was disease or injury in any way related to occupation of deceased ?Mo If so, specify
(Signature)
an Caplan M. D. A. N. CAPLAN MD (Print or Type Name)
1-9 1963 (Address) GMERMAID IT WINTHROP HAST
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
That I attended deceased from
DEC 26, 19.
2 to .......
JANUARY 9, 1963
I last saw hERlive on JAN 9,
196 .. 3, death is said to
have occurred on the date stated above, at
1:45 Pm
St WINTHROP MASS
(If nonresident, give city or town and State)
52
S (If death occurred in a hospital or institution,
WINTHROP COMMUNITY HOSPITAL
KATHERINE LEITCH
(Was deceased a U. S. War Veteran,
if so specify WAR).
NO.
3 DATE OF
DEATH
DE JAN. 9. 1963
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
3WKS
(City or Town making this return)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
TU !!
ORGANIZATION AND OUTFIT
P .10.
r :
1
SERVICE NUMBER.
6
NTHROP
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 thosdet persont 1963 FM to whom they have given bedside care during a last illness from disease on 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 froin 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.
DATE OF DISCHARGE
RANK, RATING
X
PLACE OF DEATH
Suffolk (County)
-
Winthrop (City or Town)
No .. Mount's Convalescent Home
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME. Lillian Nancy Foley ( McCormick )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
JUIST SETTALA
(a) Residence. No ...
(Usual place of abode)
Length of stay: In place of death 5 years.
6.months .......... days. In place of residence .... Oyears.
..... months ...
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January ..
1.0
1963
(Year)
(Month)
(Day)
attended deceased, from
I last saw hoalive on
JAN 10
19
.. , death is said to
m.
have occurred on the date stated above, at
2
A
INTERVAL BETWEEN ONSET AND DEATH
EMOS
Due To (b) ... ADENO CARCINOMA OF BREAST
LYN.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
DIABETES MELLITUS
ARTERIOSCLEROSIS-GEN. 5YRS.
Was autopsy performed?
No
What test confirmed diagnosis ?
CLINICAL PATH.
5 Was disease or injury in any way related to occupation of deceased ?.. If so, specify (Signature) masonb. King M. D. MYRON N. KING RIO PARENT'S
(Print or Type Name) (Address) 222 PLEASANT STA ... Date 1/12/63
6 Holy Cross Cemetery Malden
Place of Burial or Cremation (City or Town)
DATE OF BURIAL January 14 1063 19
7 NAME OF
FUNERAL DIRECTOR
Ciefred R. March
174 Winthrop St. Winthrop, Mass ADDRESS
Received and filed
JAN 1-4-4968
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED Widowed
WIDOWED
DIVORCED
UNKNOWN
female white
11 1f married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
Timothy Foley
(Husband's name in full)
12
AGE .... 80 ears.
7 Months 23 Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
housewife
(Kind of work done during most working life)
14 Industry
or Business:
own ... home
15 Social Security No ........... none
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
James McCormick
18 BIRTHPLACE OF
FATHER (City)
(State or country) Ireland
19 MAIDEN NAME
OF MOTHER
Mary Daley
20 BIRTHPLACE OF MOTHIER (City). (State or country) Ireland
21 Informant
Old .... Age .... Dept.
( Address)
Winthrop, Massachusetts
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) Health .1) Jan 14-1463
(Official Designation)
(Daté of Issue of Permit)
M 2-62-932382
FORM R-301
iled for burial permit Board of Health or its Agent. INSTRUCTIONS FOR ICAL CERTIFICATE
INT OR TYPE SE OR CAUSES OF DEATH do not enter more than one ause for each (a), (b) and (c)
sis does not mean mode of dying, as heart failure, nia, etc. It means disease, or compli- ns which caused h.
ditions, if any, hich gave rise to ove cause (a), ating the under- ing cause last.
Conditions contrib- g to death but not ed to the terminal se condition given a).
21.C
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
0
Trident Avenue
St
Winthrop, Mass.
(If nonresident, give city or town and State)
4 .I HEREBY CERTIFY , That
DEC 13
1953
to ...
JAN
10
1963
13
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
GENERAL CARCINOMATOSIS
(a)
(or) WIFE of.
Boston
5YRS,
TRUE COPY ATTE ATTEST:
SPACE FOR ADDITIONAL INFORMATION
6
DATE OF ENTERING MILITARY SERVICE .....
DATE OF DISCHARGE
RECEIVED
JAN 1 41963 AM
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
EIK
6
3
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice : JA 2 1 1063 AM (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-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
(a) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) (b) 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)
50M-9-39-926111
PLACE OF DEATH
Fssex
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
Danvers
(City or Town making this return)
5
Danvers State Hospital, Hathorne St. ( give its NAME instead of street and number) No.
Bertha Hollis
(If deceased is a married, widowed or divorced woman, give also maiden name.)
167 Shore Drive
& Winthrop
Mess.
(a) Residence. No ... ( Usual place of abode)
( If nonresident, give city or town and State)
Length of stay: In place of death
1
.years.
20
... months.
.days. In place of residence .......... years.
.months.
.... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
January
11,
1963
(Month)
(Day)
(Year)
female
9 COLOR
white
10 SINGLE
MARRIED
(write the word )
WIDOWED
or DIVORCEWidowed
4 I HEREBY CERTIFY,
That I attended deceased
from
Nov. 21.
62
January 11
19 .. to .......
I last saw
h ...... alive on
January
11
..
19 ... death is said to
have occurred on the date stated above, at .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Viral Pneumonia
General Arteriosclerosis
OTHER SIGNIFICANT CONDITIONS
NO
Was autopsy performed ?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
PARENTS
Beachmont Cemetery , 6
Everett
Place of Burial or Cremation
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