USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1959 > Part 62
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(or) WIFE of
Luigi.Limone
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.8.1.
Years.
Months.
Days
If under 24 hours
Hours ....
Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
At home
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Italy
17 NAME OF
FATHER
Joseph Cimirro
18 BIRTHPLACE OF
FATHER (City)
(State or cou
Italy
19 MAIDEN NAME
OF MOTHER
Information unavailable
20 BIRTHPLACE OF
MOTHER (City)
(State or country) Italy
21 Informant
Joseph Limone
(Address) 191 Cottage Pk Rd Winthrop
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)
Relaxete Galiza
11/23/55
(Official Designation) 1
(Date of Issue of Permit)
1-59-92 5686
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.
209
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,
no
{if so specify WAR)
Winthrop
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
17
.years ...... .. months
days. In place of residence
17
.years.
months ..
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
November 21 1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
50
to ..
no.
1959
I last saw hanalive on
20
1957, death is said to
have occurred on the date stated above, at
.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
CEREBRAL HEMORRHAGE
(a)
Due To
HYPERTENSION
(b) ....
9YRS
PARENTS
(City or Town)
DATE OF BURIAL
191 Cottage Park Road
No.
2 FULL NAME
RAFFAELA LIMONE ( CIMIRRO)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
191 Cottage Park Road
(a) Residence. No. (Usual place of abode)
10 SINGLE
(write the word)
INTERVAL
BETWEEN
ONSET AND
DEATH
5 Days
lions contrib- uth but not o he terminal olition given
apter 137, 14. requires al to print or ha cause or c death on rhcates, and 3, Acts of cires Physi- int or type nor signature.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
GECE'YLE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
F TO !..
6 2
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.
NOV 2 41959 41
V.R-301A
1
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.
48 DOLPHIN Ave
No. MYER SWARTZ
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 48 DOLPHIN
(Usual place of abode)
10
Length of stay: In place of death 'years. . months ... days. In place of residence / 0 years .. _months." . days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Nov.
21. 1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
to.
That I attended deceased from
August, 1956
Nov. 21
I last saw hihalive on
Nov. 21, 1959.
have occurred on the date stated above
6:20 A.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Cancer of @esophagus
Due To
· Carcinomatosis from
above.
Due To (c)
OTHER
SIGNIFICANT
None.
CONDITIONS
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 Charles Liberman
(Signed)
Charles Liberman
, M. D.
(Address) Winthrop Mass Date 11/211
159
6
LIBERTY PROGRESSIVE
EVERETT
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
NOV
22
1959
7 NAME OF
FUNERAL DIRECTOR
TORF FUNERAL SERVICE ING
ADDRESS
CHELSEA
Received and filed
NOV 23 1959
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
(write the word)
MARRIED
WIDOWED WIDOWED
DIVORCED
10a If married, widowed,
HUSBAND of
Aivor
ivor MELAMED
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
If under 24 hours
„Hours .....
Minutes
13 Usual
Occupation :
DEALER
(Kind of work done during most of working life)
14 Industry
or Business:
REALESTATE
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
RUSSIA
17 NAME OF
FATHER
ABRAHAM SWARTZ
18 BIRTHPLACE OF
RUSSIA
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
C.B.L
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
RUSSIA.
21 MAURICE KLICKSTEIN
Informant
38 VARICK RD NEWTON
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 Officin
205 7.7. 1959
(Official Designation)
(Date of Issue of Permit)
.
- HIS IS A ANT RECORD. s only PPROVED I‹ or black ler ribbon.
ICTIONS JR ERTIFICATE
Iving F DEATH : enter lan one 'or each ›) and (c)
es not mean of dying, cart failure, c. It means or compli- hich caused
s, if any, ve rise to zuse (a), he under- tuse last.
ns contrib-> ath but not the terminal dition given
hapter 137, 54, requires to print or cause or death on ficates. . 46, 58 9 & . 114 $$ 45, P. 38 $ 6.)
58-923886 X
Registered No. 210
[(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
AVE
St.
(If nonresident, give city or town and State)
19. 54 aid to
- (b)
6mos
INTERVAL
BETWEEN
ONSET AND
DEATH
6mos
12
22
.Years
-
Months.
.Days
PARENTS
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 follow- ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care 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.
RECEIVED
OF TOM 11. 12
THRO
NOV 2 31959 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.
211
[(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.
(a) Residence. No.
92Bartlett ..... Road
(Usual place of abode)
.St.
(If nonresident, give city or town and State)
Length of stay: In place of death ... 5.Q .. years .............. months. ....... days. In place of residence.5.0 .years. ....... ..... months .days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
November.
22
1959
(Year)
(Month)
(Day)
4 I
HEREBY CERTIFY,
That I attended deceased from
19
to.
19
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Robert Fowler ....
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE .. 7.2 .... Years ........... Months ... 26 .. 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
15 Social Security No. ..
034-18-2687-B.
Boston
16 BIRTHPLACE (City)
(State or country)
L'ass
17 NAME OF
FATHER
Willard Francis Ko Intyre
18 BIRTHPLACE OF
FATHER (City)
Chelsea
(State or country)
T'ass.
19 MAIDEN NAME
OF MOTHER
Caroline Hutchinson
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass
Chelsea
Jamaica Plain
6
.... OnegtHills.Cemetery"(City or Town)
Place of Burial or Cremation
DATE OF BURIAL November 25, 1959
19
7 NAME OF
FUNERAL DIRECTOR
alfred B. Marste
ADDRESS
774 Winthrop St. inthron
19 Received and filed NOV 25 1959
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED Tidow ed
or DIVORCED'
I last saw h ........ alive on
19 ............; death is said to
have occurred on the date stated above, at
11:05 pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Natural Causes
(a)
....
Due To
(b)
Presumably Coronary Occ
lusion
sudden
Due
(c)
· Generalized Arteriosclerosis
5 yrs
OTHER
SIGNIFICANT
CONDITIONS
none
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)
MED.
Arthur C. Murray, M.D., La22
"PRINT OR TYPE SIGNATURES
(Address)
Winthrop Bca Date 24 Nov 19 59
PARENTS
Informant
(Address)
..... 188.Virginia M. Fowler
92 Bartlett ad. Winthrop
I HEREBY CERTIFY, that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: 0,
(Signature of Agent of Board of Health or other
Thealite Offices
11/25/59
(Official Designation)
(Date of Issue of Permit)
1-301A 1
ITIONS
IRTIFICATE
ing DEATH enter in one r each and (c)
not mean of dying, rt failure, It means or compli- ch caused
if any, e rise to use (a), e under- tse last.
ns contrib- th but not 'e terminal ition given
apter 137, 4. requires to print or cause or death on icates, and , Acts of res Physi- int or type signature.
9-925686
2 FULL NAME.
RosalieGretchen Fowler
(If deceased is a married, widowed or divorced woman, give also
Me Intyre
Registered No.
No. 92 Bartlett Road
.....
INTERVAL
BETWEEN
ONSET AND
DEATH
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
TO !:
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
0
RULES OF PRACTICE
fillment of the purpose NOV.2.51959 IM ve 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
R-303 A 1
(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. 212
241-A Shirley Street, Winthrop No. BEVERLY NOLLER
S(Ii death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
r
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
241-A Shirley Street,
St
Winthrop,
(a) Residence. No.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay : In place of death .............. years .............. months .............. days. In place of residence
years.
.months ........
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
November
23,
1959
(Month)
(Day)
(Year)
9 SEX
10 COLOR
Female
White
11 SINGLE
(write the word)
MARRIED
WIDOWEDMarried
or DIVORCED
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.) Meningioma of cerebellum with acute
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
WILLIAM NOLLER
(Husband's name in full)
12 IF STILLBORN, enter that fact lere.
41
13
AGE
Years.
Months.
.. Days
If under 24 hours
.lfours .........
.Minutes
14 Usual
Occupation :
(Kind of work done during most of working life)
15 Industry
or Business :
AT home
16 Social Security N ».
None
17 BIRTHPLACE (City)
(State or country)
Boston Mass
18 NAME OF
FATHER
HARRY ENGLER
19 BIRTHPLACE OF
FATHER (City)
BOSTON MASS.
(State or country)
20 MAIDEN NAME
OF MOTHER
EDITH ALLEN
21 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
RUSSIA
22
Informant
WILLIAM NOLLER
(Address)
241 A. SHIRLEY ST. WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was hled wigh nr BEFORE the burial or transit permit was issued:
Palph C. Terenul .. 4.
Signature of Agony of Board of Health or other) Fekete Officer 11/24/59
(Official Designation) (Date of Issue of Permit)
.
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 ? (Specify type of place)
Manner of
Injury
(How did injury occur ?)
While at work ?
.. Was autopsy performed?
Yes
6 Was chsease or mjury in any way related to getupation of deceased?
(Signed Michael A. Luongo, M. D.
M. D.
(Print or Type Signature)
Boston
11/23. 59
(Address) Date
AMERICAN FREINDSHIP SOC .. . BAKER .... ST. Place of Burial, or Cremation. (City or Town) DATE OF BURIALWEST ROX 11.24 .19 ..... 5.9
8 NAME OF FUNERAL DEREALOSSBERG FUNERAL SER. ADDRESS257 BLUE HILL AVE MATT.
Received and filed
NOV 24 1959
19.
( Registrar}
PARENTS
25M-3-59-924934
PLACE OF DEATH
SUFFOLK
DEATH Injury If so, §§ 44-48. of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. 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 MANNNER Ur Nature of
5 Accident, suicide, or homicide (specify) Date and hour of injury 19
HOUSEWIFE
..
sub-tentorial cerebral edema
3.5
(Was deceased a
U. S. War Veteran,
if so specify WAR)
Mass.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
TOI
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
NOV 2 61959 AM
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 ad- ministered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "Frac- ture 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.)"
₹.302 1
PLACE OF DEATH
Suffolk
(County) Chelsea
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
Chelsea
(City or Town making this return)
Registered No.
591 213
$(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME. Baby Boy Alton
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
Qtrs. #35, Ft. Banks
1
St.winthrop Mass
nonresident, give city or town and State)
(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
3 DATE OF
Nov.24,1959
DEATH
(Month)
(Year)
(Day)
4 | 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 .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Stillborn
Due To (1)) Frythroblastosis fetalis
OTHER SIGNIFICANT CONDITIONS
yes
5 Was disease or injury in any way related to occupation of deceased? If so, specify.
H. P. Pine
(Signed)
(Address) USNH,Chelsea, Mass, 11/25/59
Woodlawn, Everett, Mass. 6
Place of Burial or Cremation Nov.25, 195gty or Town) 19
DATE OF BURIAL
R.C.Kirby, Inc.
7 NAME OF FUNERAL DIRECTOR Bennington St. ,I.Boston
ADDRESS.
Received and filed DEC 7 1959 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDingle
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 herstill born
12
AGE ....
.. Years.
.. Months ............ Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No ..
16 BIRTHPLACE (City)
(State or country)
Chelsea, Mass.
17 NAME OF FATHERHarold W.
18 BIRTHPLACE OF FATHER (City) (State or country)
Judsonia,Ark.
19 MAIDEN NAME
OF MOTHER Verne D. Bullard
20 BIRTHPLACE OF MOTHER (City) (State or country)
Garland Texas
21 H.Alton (father)
Informant.
(AddressEt Banks Winthrop Mass
A TRUE COPY ATTEST: Joseph aTurelle
(Registrar of City or Town where death occurred)
DATE FILED
Nov.25,1959
19
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. 1 .. ) 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)
25M-2-58-922072
INTERVAL BETWEEN ONSET AND DEATH
Was autopsy performed?
What test confirmed diagnosis?
M. D.
PARENTS
No. U.S.Naval Hospital
CERTIFICATE OF DEATH
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(write the word)
- TO:
.. ..
GLERS
6
IROP.
DEC -71959 AM
1-301A 1
TIONS
RTIFICATE
ing DEATH enter in one r each and (c)
not mean of dying, ert failure, . It means or compli- caused
Ich
if any, e rise to se (a), e under- Case last.
ns contrib- th but not ie terminal ition given
apter 137, 14. requires to print or e cause or death on Micates, and , Acts of res Physi- 1.nt or type di signature.
6 9-925686
PLACE OF DEATH
Suffolk (County)
INS
Winthrop (City or Town)
No. Winthrop Convelecent Home
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH H3LALAO DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
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