USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 28
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ditions contrib- death but not o the terminal condition given
::- Chapter 137, of 1954. requires cians to print or the cause or ; of death on certificates, and er 48, Acts of requires Physi- to print or type under signature.
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
July 28,
6
19
PARENTS
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Halble E fireande x (Signature of Agent of Board of Health or other) Theable Officer
. 7/26/65
(Official Designation)
(Date of Issue of Permit)
X
8 SEX
male
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWEMarried
or DIVORCED
10a If married, widowed, or divorced Ondina Nunes HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
E hr
4 days'3
Occupation :
machine operator
(Kind of work done during most of working life)
14 Industry
5 days or Business:
Commercial Filters Corp.
Was autopsy performed?
Noclinical & X-ray
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?- If so, specify
No
(Signed)
Louis E Schuif/a OMP.
M. D
Louis E Schwartz (PRINT OR TYPE SIGNATURE)
(Address19 Bennington st" Date 7-25-61 19
F. Boston
Woodlawn Everett
Registered No.
141
S(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT [(Was deceased a
St.
East Boston
Mass
(If nonresident, give city or town and State)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
OF
78 12 3
GLERK.
OFFI
3
MIN
1 (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.
WI
6.
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.
(3) Medical Examiners will investigate and certify to all deaths supposably THROP. 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 JUL 271961 PMThose 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.
ORM R-304
1
(City or Town) PLACE OF DELIVERY Suffolka (County )
2 NAME OF FETUS (if given )
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.
1.42
(If death occurred in a hospital or institution, give its NAME instead of street and number)
3 DATE OF
DELIVERY
Month )
(D)
(Year )
4 SEX
Male ... .. Female
Undetermined
5 COLOR (if
determined)
6 THIS BIRTH (Check one)
Single Twin
Triplet
7 IF MULTIPLE BIRTH, BORN :
1st.
2nd
3rd.
FATHER
8 FULL NAME Leo Marshall
14 MAIDEN NAME
MOTHER Victoria Marshall
PRESENT NAME
Victoria Marshall
9
RESIDENCE, NO.
CITY OR TOW
Earl Bolin
STAT
15
RESIDENCE, NO.
CITY OR TOWN
EurBol STAT
10 COLOR
RACE
11 AGE AT TIME OF THIS DELIVERY (Years)
22
12 PLACE OF BIRTH Bustin
mass
(City or Town)
( State or country ,
13 OCCUPATION Truckbliver
19 INFORMANT
Victoria Marshall
20 PREVIOUS DELIVERIES TO MOTHER (Do not include this fetus) 2 normal
(a) How many children are now living? 2
(b) How many children were born alive but are now dead ? None
(c) How many previous fetal deaths of ANY gestation age ?
21 LENGTH OF PREGNANCY 32
.completed
weeks
(or
FETUS 14 Oz. Grams
23 WHEN DID FETUS DIE? Before Labor
24 AUTOPSY
Yes
No
25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Died in Utero
Due To (b) Ery Thro BlasTosis DeTalks Blood Due To (c) Rho
OTHER SIGNIFICANT CONDITIONS
26 Holy Cross Cemetery Malden
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL July 29,
27 NAME OF FUNERAL DIRECTOR Vincent kopino
ADDRESS
9 Chelsea St., East Boston, Mass.
Received and filed
JUL 28 1961
19.
(Registrar )
A TRUE COPY ATTEST :
I HEREBY CERTIFY that this delivery occurred on the date stated
above at m., and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner : Louis ESduffa M. D.
Louis E Schrifta (PRINT OR TYPE SIGNATURE) 19 Bennington: Address Date Jul 27 19 6/
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued :
Talkh E: Sirianni ( Signature of/Agent of B a fond of Health or other) 7/2$61
H: O
(Official Designation )
(Date of Issue of Permit)
BROMell
Prescott
STREET
16 COLOR
RACE
17 AGE AT TIME OF 2 2 Years) THIS DELIVERY
BIRTH
Lynn (City /Town )
Mees
(State or country )
In giving CAUSE OF TAL DEATH do not enter nore than one ause for each of (a), (b) and (c)
tal or maternal dition causing al death (do t use such ms as stillbirth prematurity. ) tal and/or ma- nal conditions, ny, which gave se to above ise (a), stating underlying se last.
nditions of fetus mother which y have contrib- ed to fetal th, but, in so as is known, re not related cause given (a).
15M-6-60-928241
Winthrop Community Hospital Baby Girl Marshall
St.
/27/61
O Prescott AV
STREET
22 WEIGHT OF
Lb.
During Labor or Delivery Unknown
OF TO
OFFI
MIN
CLERK
CA
0
*
WII
6
FETAL DEATH
EXTRACT'S OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48. ACTS.OF 1960. JUL 2/71961 PM Section 2A. "Examination of records and returns of illegitimate births, or abnormal sex births, or fetal deaths, . . . shall not be permitted except .. . ".
Section 9A. When a child is born dead, after a period of gestation of not less than twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and no movement of voluntary muscle, the physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.
Section 12. " ... No birth record of a child born out of wedlock or of a child of abnormal sex, and no record of fetal death shall so be transmitted to any other city or town."
Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.
X
ORM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
.
A TRUE COPY
ATTEST :
(Registrar of City of Town where death occurred)
August 1,
19.
61
( Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Gordon W. Graham
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
AG
.Years
69
1
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.
Boston.
16 BIRTHPLACE (City)
(State or country )
Mass
Arteriosclerosis
2years
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country )
Holland
19 MAIDEN NAME
OF MOTHER
Katherine Nold
20 BIRTHPLACE OF
Pittsburgh,
MOTHER (City)
( State or country)
Penn.
Winthrop
DATE OF BURIAL
August 2,
61
19
7 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS
Winthrop, Mass.
Received and filed
AUG 10-1961
.. 19.
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Revere
(City or Town making this return)
1
PLACE OF DEATH
Suffolk (County)
Revere (City or Town )
No .... Grover .... Manor .... Hospital
§ (If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
2 FULL NAME
Gertrude E. Graham (Steinauer)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Ilılı Hermon
S
Winthrop, Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... month ... Q
„days. In place of residence 40 years. .. months .......... days.
MEDICAL CERTIFICATE OF DEATH
(a)
Residence.
No ..
( Usual place of abode)
3 DATE OF
DEATH
July
31,
(Month)
(Day)
4 I HEREBY CERTIFY.
June .... 15.
19
have occurred on the date stated above, at
(a)
Brain Tumor
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
NO.
(Signed )
George A. Haines
16 Raymond St.,
( Address )Everett
S
Winthrop
Place of Burial or Cremation
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.)
What test confirmed diagnosis ?
X-Ray
1961
(Year)
That I attended deceased from
61
to .... Jul.y ...... 31
19 .. 61 ..
I last saw Me.Malive on
July31
1961
death is said to
3:00A
m.
Due To (b) 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)
50M-9-59-926111
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
No
M. D.
.Date.
July 31 . 67
(City or Town)
21 Gordon W. Graham
Informant
( Address)
Ihh Hermon St., Winthrop
143
Registered No.
( Was deceased a
U. S. War Veteran.
if so specify WAR
DATE FILED
0.
X U.B.V
3mos,
NAME O
FATHER
Charles Steinauer
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT/ SERVICE NUMBER
AUG. 1.0.1961 AM
FORM R-302
EATH
The Commonwealth of Massachusetts JOSEPH D. WARD
ARIZONA STATE DEPARTMENT OF HEALTH BUREAU OF VITAL STATISTICS
STATE FILE NO.
4363
CERTIFICATE OF DEATH
REGISTRAR'S NO.
8.08
1. PLACE OF DEATH
A. COUNTY
Pima
B. LENGTH OF STAY
IN THIS TOWN
6 wks
IN ARIZONA
6 wks
2. USUAL RESIDENCE
A. STATE
Mass.
(WHERE DECEASED LIVED. IF INSTITUTION: RESIDENCE BEFORE ADMISSION) B. COUNTY
C. CITY
OR
TOWN
Tucson
IN CITY LIMITS
O OUTSIDE CITY LIMITS
C. CITY
OR
TOWN Winthrop
IN CITY LIMITS
OUTSIDE CITY LIMITS
D. FULL NAME OF
HOSPITAL OR
INSTITUTION
(IF NOT IN HOSPITAL OR INSTITUTION. GIVE STREET ADDRESS OF 1948 E Hedfick
D. STREET (IF RURAL, GIVE LOCATION) E. IS RESIDENCE ON A FARMI ADDRESS
-
YES O NO O
3. NAME OF
DECEASED
(TYPE OR PRINT)
(FIRST)
Helen
B.
(MIDDLE)
Grant
c.
(LAST)
Cammall
-
4. SEX
female
white
GA. MARRIED, NEVER MARRIED, WIDOWED, DIVORCED (SPEGIFT) wodowea
6B. NAME OF SPOUSE
- - -
9B. KIND OF BUSI- NESS OR INDUSTRY home
10. BIRTHPLACE (STATE
OR FOREIGN COUNTRY)
Mass.
11. CITIZEN OF WHAT
COUNTRY?
U.S.A.
12. WAS DECEASED EVER IN U. S. ARMED FORCES7 | 13. SOCIAL SECURITY (TSS, NO. OR UNKNOWN) no (IP TES, WAR OR DATES OF SERVICE)
unkRown
14A. FATHER'S NAME
unknown
148. BIRTHPLACE
(STATE OR COUNTRY)
15A. MOTHER'S MAIDEN NAME
unknown
15B. BIRTHPLACE -
16. INFORMANT'S SIGNATURE
mitte
ADDRESS P.ODPREY 1115
17. DATE
OF
DEATH
(MONTH) May
(DẠY)
(TEAR) 1901
18. CAUSE OF DEATH ENTER ONLY ONS CAUSE PSR LINE FOR (A). (B), (C).
1. DISEASE OR CONDITION DIRECTLY LEADING TO DEATHt (A)
.
Cerebral /frenter's)
INTERVAL BETWEEN ONSET AND DEATH
ITHIS DOES NOT MEAN THE NODE OF DYING, SUCH AS HEART FAILURE. ASTHENIA. ETC. IT MEANS THE DISEASE. INJURY. OR COMPLICATION WHICH CAUSED DEATH.
ANTECEDENT CAUSES MORBID CONDITIONS, IF ANY, GIVING RIBE TO THE ABOVE CAUSE (A) STATINO THE UN. DERLYING CAUSE LAST. DUE TO (C)
DUE TO (B) Cert. SEGerais
geters
11. OTHER SIGNIFICANT CONDITIONS CONDITIONS CONTRIBUTING TO THE DEATH BUT NOT RELATING TO THE DISEASE OR CONDITION CAUSING DEATH.
PLACE DISSASE CONTRACTED. 19A. DATE OF OPERATION
19B. MAJOR FINDINGS OF OPERATION
20. AUTOPSY? YES
0 NO
21. 1 HEREBY CERTIFY THAT I ATTENDED THE DECEASED FROM.
ALIVE ON 22A. SIGNATURE
AND THAT DEATH OCCURRED AT (DEGREE OR TITLE)
22B. ADDRESS
22C. DATE SIGNED
23A. ACCIDENT
SUICIDE
HOMICIDE
NATURAL CAUSE
(SPECIFY)
AL CE
23D. TIME (MONTH) OF
(DAY)
(THAN) ( HOUR )
23F. HOW DID INJURY OCCUR?
INJURY
M
24A. CORONER'S SIGNATURE
24B. ADDRESS
24C. DATE SIGNED
25A. BURIAL O CREMATION O REMOVAL D
258. DATE May 9/61
25C. NAME OF CEMETERY OR CREMATORY Evergreen Crematorium
25D. LOCATION (CITY, TOWN,.OR COUNTT) (STATE) Tucson, Arizona
27B. AD
AND REGISTRAR
26A. DATE REC -LOCAL REG. -10-6
27A. FUNERAL DIRECTOR'S SIGNATURE err Mortuary & Rieu
AT EMBALMER'S SIGNATURE
288. EMBALMER'S 226 FERT NO
JON
Received and filed
19
(Registrar of City or Town where death occurred )
27,1961
( Registrar of City or Town where deceased resided )
DATE FILED
Not Be tes l
19
U
NON- RESIDENT
A.
7. DATE OF BIRTH DAY
NONTH YEAR Jan. 28 1881
8. AGE (IN TEARS| IF UNDER 1 YEAR LAST BIRTHDAT) NONTNS DAYS 80
IF UNDER 24 HRS HOURS
NIN.
-
9A. USUAL OCCUPATION (GIVE KIND OF WORK DURING MOST OF LIFE SVEN IF RETIRED) housewife
(STATE OR COUNTRY)
MEDICAL CERTIFICATION
10
C /THAT I LAST SAW THE DECEASED
&M. FROM THE CAUSES AND ON THE DATE STATED ABOVE.
238. PLACE OF INJURY (E.G., IN OR ABOUT HOME,
FARM, FACTORY, STREET, OFFICE BLDG., ETC.)
23C. (CITY OR TOWN) (COUNTY) (STATE)
NOT WHILE
23E. INJURY OCCURRED
WHILE AT
WORK DI
AT WORK
26B, REGISTRAR'S SIGNATURE
FORM VS-2 REV. 8-8-60 -. 25
H
PUNCHED VERIFIED
BIRTH NO.
Suffolk
B. COLOR OR RACE
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
ORM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
n. C.
PLACE OF DEATH
Essex
(County )
1
Danvers
(City or Town)
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 return)
Registered No. 145
S (If death occurred in a hospital or institution, Danvers State Hospital, Hathorne st. ( give its NAME instead of street and number) No ...
2 FULL NAME Charles .... Flanagan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
( Was deceased a
U. S. War Veteran,
(if so specify WAR, ...... no.
(a) Residence. No. 86 Plumner Avenue St. Winthrop Mass.
( Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death ._..... years ....... months.
1.Says. In place of residence .......... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
25
(Day)
1961
( Month)
(Year)
8 SEX
male
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDWidowed
4 I HEREBY CERTIFY,
That I attended
deceased
from
April. 6,
19:59
to ...
July .... 25.
19
61
I last saw
h. 1.Mive on
July.25,
19 ... 61death is said to
have occurred on the date stated above, at 5:508am.
INTERVAL
BETWEEN
ONSET AND
DEATH
(or) WIFE of.
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .Generalized ... Arteriosclerosis
years
11 IF STILLBORN. enter that fact here.
12
AG
78
Years.
8
.Months.
.. 1.6.Days
If under 24 hours
.Hours ........
Minutes
13 Usual
Occupation :
Retired .... Fireman
(Kind of work done during most of working life)
14 Industry or Business :
15 Social Security No.
none
16 BIRTHPLACE (City)
(State or country)
M998.
17 NAME OF
FATHER
Patrick Managan
18 BIRTHPLACE OF
Unknown
FATHER (City)
(State or country )
Ireland
19 MAIDEN NAME OF MOTHER Elizabeth Martin
20 BIRTHPLACE OF
Unknown
Holy Cross Cemetery, Malden, Mass 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
July 27,
1967
21 Informant ( Address )
Mary E. She ehan
Hathorne, Mass.
7 NAME OF FUNERAL DIRECTOR Arthur J. O'Maley
ADDRESS Winthrop ...... Mas.s.
Received and filed AUG 15-1961 19
( Registrar of City or Town where deceased resided )
PARENTS
50M-9-59-926111
Due To (b) resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To (c)
OTHER
? Cancer Intestinal
SIGNIFICANT
CONDITIONS
tract
Was autopsy performed ?
no
What test confirmed diagnosis ? clinical & Laborato
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
( Signed )
Andrew Nichols III
M. D.
(Address) Hathorne, Mass. Date
7-25-1967
MOTHER (City)
(State or country )
Ireland
A TRUE COPY
Jemily. Tooming
ATTEST :
(Registrar of City or Town where death occurred )
DATE FILED
July 31,1:
67
Boston
10a If married, widowed, or divorced
HUSBAND of
Lillian G. Fraser
(Give maiden name of wife in full)
RECEIVED
TOW
OF
GLEA
1410
MIN
5.
AUG 1 5 1961
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
ORM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
m.C.
PLACE OF DEATH
Essex (County )
Denvers (City or Town)
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 return)
Registered No.
If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
William F. Crowley
( If deceased is a married, widowed or divorced woman, give also maiden name.)
43 Loring Rd.
x Winthrop, Mass.
(a) Residence. No ....
( Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years.
.. months.
18
days. In place of residence .......... years. .months .......... days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
( write the word)
( Month)
(Day)
( Year)
4 I HEREBY CERTIFY.
That I attended deceased from
July 1l .
61
August 1
to ...
19
61
death is said to
have occurred on the date stated above, at
INTERVAL BETWEEN ONSET AND DEATH
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
72
Years
6
13
If under 24 hours
.....
.. Hours .......
Minutes
13 Usual
Occupation:
Retired Engineer
( Kind of work done during most of working life)
14 Industry or Business : 011-18-0818
15 Social Security No.
Boston
16 BIRTHPLACE (City)
(State or country)
Mass.
OTHER Diabetes Mellitus
What test confirmed diagnosis ?
Clinical & Laborato
5 Was disease or injury in any way related to occupation of deceased ? If so. specify
( Signed )
Andrew Nichols III
M. D.
( Address )
Hathorne, Mags. 8-1-
61
19.
Winthrop Cemetery, 6
Winthrop, Mass.
( City or Town)
DATE OF BURIAL
August 3,
61
19
21
Informant
( Address )
Hathorne, Mag.s.
7 NAME OF FUNERAL DIRECTOR
Richard C. Kirby, Inc
ADDRESS E. Boston, Mass.
ATTEST :
( Registrar of City or Town where death occurred)
DATE FILED August 4,51
1
(a) (b) 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)
50M-9-59-926111
3 DATE OF
DEATH
« resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.)
SIGNIFICANT
CONDITIONS
Due To
Generalized Arteriosclerosis
years
years
17 NAME OF
FATHER
William Crowley
PARENT'S
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country )
Mass.
19 MAIDEN NAME
OF MOTHER
Mary E. Clinton
20 BIRTHPLACE OF
MOTHER (City)
Boston
Mass:
(State of country)
Mary L. Sheehan
A TRUE COPY
Josep J. Toomey
Received and filed AUG 15-1981 19
( Registrar of City or Town where deceased resided)
10a If married, widowed, or divgertrude Walsh
HUSBAND of
(Give maiden name of wife in full)
I last saw
Malive on
August 1
19
4:108
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cerebral Hemorrhage
weeks
MEDICAL CERTIFICATE OF DEATH
August
1.
1961
1
No
Danvers State Hospital , Hathorn
( Was deceased a
U. S. War Veteran,
W.W. I
(if so specify WAR
married
61
Months.
Davs
Was autopsy performed ?
no
Place of Burial or Cremation
RECEIVED
TOWA
71 12 3
CLERK
1-1-10
S
5
WI
-
THR
AUG 151961 AM
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
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
Registered No.
Mi
2 FULL NAME
Marion
Agnes
Shea
[(Was deceased a
U. S. War Veteran,
{if so specify WAR)
NO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
5 Sagamore Ave.
St.
Winthrop, Mass.
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death .............. years. ......... months. 11
50
-
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 DIVORCED
(write the word)
SINGLE
10a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 7 7 Years.
Months.
.Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
OFFICE
CLEARKT
(Kind of work done during most of working life)
14 Industry
or Business :
COURT HOUSE
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
M.15
17 NAME OF
JEREMIAH A SHEA
18 BIRTHPLACE OF
FATHER (City)
(State or country)
IRELAND
19 MAIDEN NAME
OF MOTHER
MARY A (SHEA)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
MASS
21 HENRY V MULLEN
Informant
(Address) / OSWAKEFIELD ST READING
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
HINTHIPOP
Received and filed
AUG 3 - 1961
19.
(Registrar)
11 DAYS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
GENERAL ARTERIOSCLEROSIS
3 YRS.
Was autopsy performed?
No .
What test confirmed diagnosis ?
X-Ray- operation.
5 Was disease or injury in any way related to occupation of deceased? ...... If so, specify ...
(Signed)
, M. D.
MYRON IN. KINGM.D
(PRINT OR TYPE SIGNATURE)
Date. (Address) 222 PLEASANT SI 8/1/6/
6
CALVARY
LA INI
BOSTON
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
AVG
4
1961
PARENTS
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or, transit permit was issued: Ralph 6. Percannex Signature of Agent of Board of Health or other) Thealth Officie 8/5/61
| (Official Designation)
(Date of Issue of Permit)
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, 1, etc. It means ease, or compli- . which caused
itions, if any, gave rise to cause (a), g the under- cause last.
nditions contrib- o death but not to the terminal condition given
- Chapter 137, 1954. requires ans to print or he cause or of death on ertificates, and 48, Acts of equires Physi- print or type nder signature. 1. C.
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