USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 37
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M. D
PAUL
C. BARSAM
(PRINT OR TYPE SIGNATURE)
(Address)
MASS. MEN. HOSP Date
July 3061
Vilkomer Cemetery melrose
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Benjamin. F. Solomon
ADDRESS
420 Harvard St Brookline
July 6.
19 61
19
21
Informant
31 Visst Boulevard Rd Newton Care
1
[ ( Was deceased a
U. S. War Veteran.
lif so specify WAR)
W.W.I
WINTHROP
MASS.
( If nonresident, give city or town and State)
MÉMORIAL HOSP.
No.
R-301A 1
PARENTS
18 BIRTHPLACE OF
FATIIER (City)
(State or country)
CORONARY HEART DISEASE.
4
A TRUE COPY ATTIST. Charles it Mackie Wat Registrar
- = CEIVED
TOWA
IF
MLERK
3
3
6
HROB
OCT 2 51961 AM
X
PLACE OF DEATH
SUFFOLK (County BOSTON (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT- OF - TOWN To be filed for burial permit with Board of Health or its Agent. 85
Registered No.
[(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
WILLIAM HENRY WALPOLE
2 FULL NAME
( Middle Name)
( Last Name)
( First Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
119 RIVER STREET- RD
WINTHROP.MASS
( If nonresident, give city or town and State)
Length of stay: In place of death.
years.
months
9 days. In place of residene
50
years ..
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
MARRIED
(write the word)
WIDOWED
of DIVORCED TAPRIES
4 1 HEREBY
CERTIFY
.
That I attended deceased from
JUNE ..... 26
161, 1
to ..
JULY
7
61
I last saw h. I.Mlive on
JULY 7
16I, death is said to
have occurred on the date stated above, at ..... 2 ..... 3 7 A .... 111.
INTERVAL
(or) WIFE of
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) ROUTE RENAL FAILURE
BETWEEN
ONSET AND
DEATH
GDAUS
Due To
(b) LOWER NEPHRIN NEPHRESIS
Due To
(c)
OTHER
SIGNIFICANT ACUTE MECKLES
CONDITIONS
DIVERTICULUNS
Was autopsy performed?
VIES
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify
(Signed)
FRANKLIN E BALLHÄR
M. D
( Address)
1180 BIENCON ST
Date ..
7/7/6/19
WINTHROP
a
Place of Burial or Cremation
(City or Town)
WINTHROP
DATE OF BURIAL
JULY 10
19.41
21
Informant
7 NAME OF
FUNERAL
DIRECTOR Maurice N Ruby
ADDRESS
WINTHROP
JUL 11 1961
19
( Registrar)
PARENTS
17 NAME OF
FATHER
JOHN F WALPOLE
18 BIRTHPLACE OF
FATHIER (City)
MILFORD
(State or country)
MASS
19 MAIDEN NAME
OF MOTHER
MARY A GERMAN
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
MASS
BENTHAL 1/4 RIVEN RD WINTHROP.
HALPOLE
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)
2803
7-7-61
(Official Designation)
(Date of Issue of Permit)
V.B.
- 8145
R-301A 1
CTIONS R IRTIFICATE
ving DEATH enter an one or each ) and (c)
not mean of dying, ul failure, . It means or compli- ch caused
, if any, e rise to use (a). e under- se last. C . ns contrib- th but not ie terminal ition given
Chapter 137, 54. requires i to print or hcause or death on ficates, and 8, Acts of hires Physi- rint or type Ir signature.
125 1961
No. FAULKNER HOSPITAL
0
I ( Was deceased a I' S War Veteran,
(if so specify WAR)
NO
10a If married, widowed
HUSBAND of
BERTHA C
O'HARA
0
(Give maiden name of wife in full)
( Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 76 Years
Months.
Days
lí under 24 hours
llours ....
.Minutes
13 Usual
WHOLESALE PAPER. MER
Occupation :
(Kind of work done during most of working hfe)
14 Industry
or Business :
PRINTING PAPER
15 Social Security No.
MILFORD
16 BIRTHIPLACE (City)
(State or country)
MASS
MILFORD
(a) Residence. No. ( L'sual place of abode)
3 DATE OF
DEATH
JULY 7
1.9.6.1
(Month)
(Day)
(Year)
(PRINT OR TYPE SIGNATURE)
A TRUE COPY ATTUSE: Cruris à Martie City Regerar
TO:
0
6
THROP.
OCT 251961 AM
A R-301A
1
PLACE OF DEATH
Suffolk (County) Boston (City or Town)
The Commonwealth of Massarmiarts, UIT - OF - TOWN EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No.
[(If death occurred in a hospital or institution,
St. [give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
-
( If deceased is a married, widowed er divorced woman, give also maiden name.)
Revere
St.
Winthrop,
Mass.
(If nonresident, fivy 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
3 DATE OF
DEATH
July
8, 1961
(Bay)
(Year)
(Month)/
4 I HEREBY CERTIFY
That I attended deceased from
July 6, 1961, 0
July
8
1961
I last saw him alive on July 8
19 61, death is said to
have occurred on the date stated above, at
3:15 A.m.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) PREMATURITY
Subarachnoid hemorrhage
Due To
(b)
UNKNOWN
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?...
YES
What test confirmed diagnosis ?...
Autopsy
5 WVas disease or injury in any way related to occupation of deceased ? If so. specify
(Signed).
319 tonawet and Date 7/896
6 Winthrop Cemetery
Place of Burial or Cremation (City or Town)
DATE OF BURIAL July ..... 10. 19.61
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O' Maley
Winthrop, Mass
ADDRESS
JUL 12 1961
.19 Charles A. of Ina (Referir"
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
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
Years.
Months
1
. 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)
Massachusetts
17 NAME OF
FATHER
Daniel Joseph Duggan
18 BIRTHPLACE OF
Chelsea'
FATHER (City)
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Margaret Flannery
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Winthrop Mass.
21 Boston-Lying- In- Hospital
Informant
(Address)
221 Longwood Ave. 1
I HEREBY CERTIFY that/a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Jacqueline Dorato
(Signature of Agent of Board of Health or other)
2815
7 10 61
(Official Designation)
(Date of Issue of Permit)
-THIS IS A VENT RECORD. e only APPROVED ink or black riter ribbon.
RUCTIONS FOR . CERTIFICATE giving OF DEATH
not enter than one for each (b) and (c)
does not meon le of dying. heart failure, etc. It means se. or compli- which caused 0,5
ons, if any gave rise to cause /(a), the under- cause last.
tions contrib .. death but not the terminal ondition given
Chapter 137, 954, requires s to print or cause or f death on tificates. \P. 46, 95 9 & .P. 114 45, AP. 38 : 6.)
25 1961
IO-58.923686
Boston-Lying-In-Hospital
FRANK Baby "Duggan 2 FULL NAME
( M'as deceased a U. S. War Veteran,
if so specify WVAR)
(a) Residence. No. 286
(Usual place of abode)
To be filed for burial permit with Board of Health 6 or Its Agent. 06502
PARENTS
, M. D.
Winthrop
Boston
A TRUE COPY ATTESTE Chris it Mackie Gry Registrar
HECEIVED
TOWA
F
. 1
3
ILERK
3
-
C.
65
VTHROP
OCT 2 51961 AM
X
SUFFOLK
(County)
BOSTON
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT - OF - TOWN To be filed for burial permit with Board of Health? or its Agent.
06591
CHILDREN'S HOSPITAL MEDICAL CENTER. {(If death occurred in a hospital or institution, No.
MICHELLE
WOOD
( Middle Name) (Last Name) ( If deceased is a married, widowed or divorced woman, give also maiden name.) ( First Name)
30 PLUMMER AVE.
WINTHROP, MASSACHUSETTS
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
years
1
1
months. days. In place of residence years.
.months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
JULY
12
1961
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY
That
Attended deceased from
61
JUNE
11
61
19
er
JULY 12
61
I last saw h ........ alive on
19
... , death is said to
have occurred on the date stated above, at
m.
INTERVAL
BETWEEN
ONSET AND
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
YES
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
M. D
F3 PROSENT ERGER
(PRINT OR TYPE SIGNATURE)
(Address)3.00LONGTTOODAVEDa. JULY 12 9 6]
WinkranCemetery Winthrop 6
I'lace of Burial or Crerdition
(City or Town)
7 NAME OF
FUNERAL DIRECTOR
Ernest P. Cosaima
147 Winthrop I. Salon
ADDRESS
Charles Raised med filed JUL 14-1961 19 Va H. Machine istrar)
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
I ments
day
If under 24 hours
AGE
Years.
Months.
.. Days
Ilour s ............ .Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTIIPLACE (City)
(State or country)
Winthrop
1155
17 NAME OF
FATHER
Frederick Wood
18 BIRTHPLACE OF
FATIIER (City)
(State or country)
Vermont
19 MAIDEN NAME OF MOTHER
Mary O'Byrne
20 BIRTIIPLACE OF
MOTHER (City)
(State or country)
Vermon
-
Frederick Wood
1 HEREBY CERTIFY that a satisfactory standard certificate of death was Gled with me BEFORE the burial of transit permit was issued: acquisire iMano
(Signature of Agent of Board of Health or other)
2882
(Date of Issue uf Permit)
(Official Designation)
X
R-301A 1
CTIONS R ERTIFICATE
ving F DEATH enter an one or each ) and (c)
not mean of dying. art failure, c. It means or compli- ich caused
if any, e rise to use (a), e under- ise last.
ns contrib. th but not he terminal ition sign 59.3
Chapter 137, 54. requires Es to print or cause or death on ificates, and 8. Acts of ires Physi- rint or type 'r signature.
25 1961
028145
PLACE OF DEATH
2 FULL NAME
St. { give its NAME instead of street and number) PHYSICIAN - IMPORTANT [ ( Was deceased a U. S War Veteran.
(if so specify WAR)
(a) Residence. No.
HOSPITAL of abode)
JULY
12
19
4:40 A
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
MULTIPLE CONGENITAL ANOMALIES DEATH
(a)
PARENTS
Middlebury
Brandon
DATE OF BURIAL July 13 1001 21 Informant (Address) 20 Plummer Avenue
Registered No.
A TRUE COPY ATTEST: Charles St Mackie (a Registrar
- ICEVED
OF
TOWA
-1
#3 ERK
6
H
OCT 2 51961 AM
C
X
PLACE OF DEATH
Suffolk
(County ) Chelsea
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
Chelsea
(City or Town making this return) S
344
Registered No.
[ {If death occurred in a hospital or institution,
.. St.
1
give its NAME instead of street and number)
2 FULL NAME John Albert Wright
(If deceased is a married, widowed or divorced woman, give also maiden name.)
U. S. War Veteran,
(if so specify WAR,
(a)
Residence.
No.
100a Summit Ave.
1
siinthrop Mass.
( Usual place of abode)
hospital
( If nonresident, give city or town and State)
Length of stay: In place of death.
Gears ....
Q.months ....... ]days. In place of residence ...
3.5%.
......... months .......... doy s.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July 15.1961
( Month ) (Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
July 6, 19 61
to ..
July .... 15.
19 ... 61
I last saw haddlive on
July .... 15
161 .. , death is said to
have occurred on the date stated above, at
12:304.
INTERVAL
BETWEEN
ONSET AND
DEATH
(a) Perforated duodenal ulcer
Due To with peritonitis
(b)
Due To
Arteriosclerotic heart
(c)
disease-congestive heart failure
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ?
yes
What test confirmed diagnosis ?
autopsy
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
16 BIRTHPLACE (City)
(State or country)
Boston, Mass.
17 NAME OF
FATHER
James F.Wright
18 BIRTHPLACE OF
FATHER (City)
...
Boston, Mass.
(State or country)
19 MAIDEN NAME zabeth Magee OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) Ireland
( State or country)
Soldiers' Home Record
(Address Office , Chelsea, Mass.
A TRUE COPY
FUNERAL DIRECTOR Winthrop, Mass.
ADDRESS
Received and filed
OCT-10-1961
19
( Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
Male
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDMarried
10a If married, widowed, or divorced
HUSBAND of
Irene .. Doherty
( Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years ....
.Months
Days
If under 24 hours
...
.Hours ........ Minutes
13 Usual
Occupation :
Investigator
( Kind of work done during most of working life)
14 Industry
or Business :
not known
15 Social Security No. 010-09-7629
PARENTS
(Signed )
Klaus G.M.Reverdy
M. D.
Soldiers' HomeHosp. 7/15/61
Milton Cem., Milton, Mass. 6
Place of Burial or Cremation- July 18,1961 19
Town)
DATE OF BURIAL
7 NAME OF Arthur J.O' Maley
50M-9-59-926111
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.)
THIS IS A PERMANENT RECORD
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 .
C
RM R-302
1
(City or Town)
No Soldiers' Home Hospital
CERTIFICATE OF DEATH
(Registrar of City or Town where death occurred)
DATE FILED
July 15,1961
19
V.B.
21 Informant
ATTEST :
The Joseph aTerrell
( Was deceased a
WWWI
( write the word)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
76
11
23
TOW
ERIT
6
HROP.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
Aug. 7,1918 OCT - 91961 AM
DATE OF DISCHARGE
Apr.30,1919
Private
RANK, RATING
ORGANIZATION AND OUTFIT
U.S.Marine Corp.
SERVICE NUMBER
136803
PLACE OF DEATH
Suffolk (County)
East Boston (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
OUT - OF - TOWN To be filed for burial permit with Board of Health O or its Agent 07062
Registered No.
St. } give its NAME instead of street and number) No. Princeton-Shelby Nursing Home
2 FULL NAME
Frances Yvonne Lanou Dasch
(First Name)
( Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woinan, give also maiden name.)
f ( Was deceased a ¿U' S. War Veteran.
lif so specify WAR)
(a) Residence. No. 44 Cottage Park Road
St
Winthrop, Mass
( L'sual place of abode)
Length of stay:
In place of death.
years ...
5 months.
days
In place of residence 7,7 years ...... .. months. .days.
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
24
1967
(Month)
(D)ay)
(Year)
4I HEREBY CERTIFY
NOV
4
19.49,
to.
JULY 24
.That I attended deceased from
1961
I last saw h. Clive on
JULY
24
, 19. 61, death is said to
have occurred on the date stated above, at
2:40 Pm.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
GENERAL CAROHEMATOSIS
WITH-PARAPLEGIA
Die To.
(b)
TIMETASTASIS TO SPINE
Due To
(c)
ADENO CARCINOMA RT. BREAST
OTHER SIGNIFICANT CONDITIONS NONE
Was autopsy performed?
Ne
What test confirmed diagnosis? OPERATION + CLINICAL
5 Was disease or injury in any way related to occupation of deceased? .... If so, specify
(Signed)
.. , M. D
MYROOS N. KING (J.D)
(PRINT OR TYPE SIGNATURE)
(Address) 222 PLEASANT ST Date JULY 26 1961
6 Winthrop Cemetery, Winthrop, Mas. Place of Burial or Cremation (City or Town)
DATE OF BURIAL July 27,1961 19
7 NAME OF
FUNERAL DIRECTOR
alfred B. Weiss
ADDRESS
174 Winthrop St. Winthrop,
Received and filed /JUL2- 1961 Macke 19
(Registrar)
8 SEX
female
9 COLOR
white
10 SINGLE
(write the word)
widowed
MARRIED
WIDOWED
of DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Eugene Carl Dasch
(or) WIFE of
(Husband's name in full)
II IF STILLBORN, enter that fact here.
12
AGE
67 Years 6
Months.
29 Days
If under 24 hours
Hours.
.......
.Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Winthrop Community Hospital
15 Social Security No.
023-18-3889
16 BIRTHPLACE (City)
Burlington
(State or country)
Vermont
Q PARENTS
17 NAME OF
FATHER
Frank S. Lanou
18 BIRTHPLACE OF
FATIIER (City)
St. Jacques
(State or country)
Juebec
19 MAIDEN NAME
OF MOTHER
Emilie Rousseau
20 BIRTIIPLACE OF
.
MOTHER (City)
Burlington
(State or country)
Vermont
I
Informant
Jugene Carl Dasch, Jr.
(Address) An Cottage Park Road Winthro
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the . burial or transit permit was issued: 1
„.a.s.s ..
alianreal
(Signature of Agent of Board of Health or other)
3049
7/26/61
(Official Designation) (Date of Issue of Permit)
V.B
T
ICTIONS OR CERTIFICATE
iving F DEATH
t enter han one for each b) and (c)
's not mean of dying, cart failure. c. It means , or compli- hich caused
s, if any, ve rise to uuse (a), he under- ause last.
ions contrib- ath but not the terminal dition given m.C
Chapter 137. 954. requires ns to print or e
cause or of death on tificates, and 48, Acts of quires Physi- print or type er signature.
25 1961
928145
R-301A 1
CERTIFICATE OF DEATH
[(If death occurred in a hospital or institution,
PHYSICIAN - IMPORTANT
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
1400
admitting clerk
JUS ATTLIT:
8 martie Ln. Bepetrar
TOWA
CLERK
3
C.
6
הנ
OCT 251961 AM
X
M R-303 A
1
(County) BOSTON
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
OUT - OF - TOWN To be filed for burial permis with Board of Health 90 or itz
Registered No.
[(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
No.
PHYSICIAN - IMPORTANT
2 FULL NAME
FREDERICK R.
HARTY
f (Was deceased a {U. S. War Veteran,
( First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
158 Highland Avenue
Winthrop, Mass.
(a) Residence. No.
(Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay: In place of death ...
years ...
months.
.days.
In place of residence
25 years.
months ..
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August
2.
1961
(Month)
(Day)
(Year)
9 SEX
Male
10 COLOR
White
MARRIED
WIDOWED M
or DIVORCEyarried
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.) Pulmonary embolus following fracture of femur; Parkinsonit.i.
!la If r
Margaret M. Caffrey
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
AGO
Years.
.Months ..
Days
If under 24 hours
Hours
Minutes
14 Usual
Occupation :
Retired.
Investment ..... Broke
(Kind of work done during most of working life)
15 Industry
or Bu iness:
Stocks & Bonds
16 Social Security No.
033-26-0792
Bo.s.t.on
17 PIRTIIPLACE (City)
(State or country)
Mass
18 NAME OF
FATHER
James Harty
19 BIRTHPLACE OF
FATHER (City)
Petersham
(State or country)
Mass
20 MAIDEN NAME
OF MOTHER
Rose Fitzgerald
21 BIRTHPLACE OF
Easthampton
MOTHER (City)
(State or country)
Mass
22
Informant
Margaret . M. Harty
(Address) 158 Fachland Ave. Winthrop I HEARBY CERTIFY that a satisfactory standard certificate of death bles with me BEFORE the burial of topay permy was issued; was
(Signature of Agent of Board of Health or other)
918877
(Official Designation)
(Date of Ing of Permite/
TX
A TENMANENT REGVAD, Every Item of
of Death. See reverse side for additional information. See also Chap. 33, 5§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that it may be properly cl csi jed under the International Classification of Causes information should be carefully supplied, MEDICAL EXAM INERS should state CAUSE AND MANNER OF
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
50M-6-60-928145
10
CI 5 1961
PLACE OF DEATH
SUFFOLK
Was autopsy performed ?
Ycs.
6 Was disease or injury in any way related to orcupaxion ofdeceased ?
If so, specify
(Signed)
Michael A. Luongo/M.D.
BostUhr Type Signature)
8/3
61
(Address) Date
7
Cedar Grove Cem
Boston Mass
Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL
August 7
1967
8 NAME OF
FUNERAL DIRECTOR
Arthur J. O' Maley
ADDRESS
Winthrop, Macc
Received and filed
AUG S 1001
( Registrar)
PARENTS
-
5 Accident, suicide, or homicide (specify) ... Ccicont.
Date and hour of injury
19
61
IF ACCIDENTAL, was injury causally related to the death?
Injury occur ?
Where did
Plymouth, Noss.
(City or town and State)
Did injury occur in or about. home, on farm, in industrial place, or in
public place ?
Hospital ..
Manner of
Fall
irem chair.
Injury
(How did injury occur ?)
Nature of
Injury
While at work?
(Specify type of place)
M. D.
§§ 44-48.
MASSACHUSETTS GENERAL HOSPITAL
{if so . specify WAR)
WW#1
11 SINGLE
(write the word)
A TRUE COPY ATTEST Frank It. Mackie Cty kesim
TO
IF
-
1.110
isin
19-
M:"1
CLERK
6 5
THROP
OCT 2 5 1961 AM
X
R-301A
I
BOSTON
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD "SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT OF TOWN To be filed for burial permit with Board of Health or its Agent. 02182
Registered No.
f(If death occurred in a hospital or institution, St. Į give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
Annie Grinnell
(First Name)
( Middle Name)
( Last Name)
f ( Was deceased a U. S. War Veteran. no
{if so specily WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.26 Emerson Road
(L'sual place of abode)
St.
Winthrop, Massachusetts ..
( If nonresident, give city of town and State)
Length of stay: In place of death.
years ..
months
1. days
In place ol residence
.60years ..
.. months ..
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX F
9 COLOR
W
10 SINGLE
MARRIED)
WIDOWED
or, DIVORCESingle
4I HEREBY CERTIFY,
August 7
1901
to ..
August
19
10a If married, widowed, or divorced
HUSBAND ol
(Give maiden name of wile in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Pulmonary Edema
Due To,
(b)
Myocardial Infarction
Due To
Old with recent extension
(c)
Coronary Heart Disease
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
yes
What test confirmed diagnosis?
autopsy.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
M. D
Charles L. Clay, M. D.
(PRINT OR TYPE SIGNATURE)
(Address) Ass's. Dle., Moss Gon'L Mars, Date August 7, 61
6
Fairview ..... Cemetery.
Jefferson, ... L
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
August
10
19
61
7 NAME OF
FUNERAL DIRECTOR
Richard .... Hall., ......... D ..
ADDRESS
Waldoboro, Laine
.....
Received Mind filed
Charles It Mackie .. 19
(Registrar)
( PARENTS
18 BIRTIIPLACE OF
FATIIER (City)
(State or country)
Appleton, Maine
19 MAIDEN NAME
OF MOTHIER
Lucinda Grinnell
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Appleton, Maine
21 Edward Grinnell
Informant
(Address)
RED Appleton Meiner
I HEREBY CERTITY that a/MItisfactoty/standard certificate of death
was flied with me BEFORE/
burial//tranche mit was issued:
(Signature of Agent of Board of Health or other),
A18468
Chuy 8,190-1
(Official Designation)
(Date of Issue of Permit)
CTIONS OR ERTIFICATE
iving F DEATH t enter han one for each ) and (e)
s not mean of dying, at failure, c. It means or compli- ich caused
s, if any, ve rise to use (a). se under- use last.
ans contrib- ath but not he terminal dition given
420.1
: Chapter 137, 954. requires lis to print or . cause or f death on ificates, and 148, Acts of tuires Physi- orint or type 1 er signature. IC. Irector se only Ink. 1 25 1961
× 28145
PLACE OF DEATH
·SUFFOLK 1 ..
(Month)
(D)ay)
(Year)
That weattended deceased from
61
Welast saw h ... eafive on
August 7
19 [1] death is said to
have occurred on the date stated above, at
9:25 Pm.
INTERVAL
BETWEEN
ONSET AND
DEATH
2 day
s 12
AGE ..... 68.Years.
Q Months.
.6 .... Days
11 IF STILLBORN, enter that fact here.
If under 24 hours
.Hours.
.Minutes
3 days13 Usual
Occupation :
Stenographer
3 yrs
(Kind of work done during most of working lile)
24 yVIG14 Industry
or Business :
Various Industries
15 Social Security No.
no
16 BIRTHPLACE (City) Appletor, Maine (State or country)
17 NAME OF
FATHER
George Grinnell
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