Town of Winthrop : Record of Deaths 1961, Part 41

Author: Winthrop (Mass.)
Publication date: 1961
Publisher:
Number of Pages: 542


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 41


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51


X


R-301A


1


Tirthron


(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.


206


Registered No.


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


PHYSICIAN - IMPORTANT


2 FULL NAME A John ( First Name) (Middle Name)


Orrall


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


(Last Name)


{if so specify WAR)


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


(a) Residence. No.


(Usual place of abode)


Length of stay: In place of death ..


.. years.


3


months.


8


.days.


In place of residence .. 5.Q .... years.


months ............ days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Male


9 COLOR


White


MARRIED


WIDOWED


or DIVORCED


Married


10a If married, widowed, or. divorsed


winifred Ives


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


AGE


Years


Days


If under 24 hours


Hours .............. Minutes


13 Usual


Occupation :


President


(Kind of work done during most of working life)


14 Industry


or Business:


Printing Co.


15 Social Security No.


023-10-9003


16 BIRTHPLACE (City)


Boston


(State or country) Lass.


17 NAME OF


FATHER


George Orrall


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Unable to obtain


19 MAIDEN NAME OF MOTHER


Christine Sissler


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


Unable to obtain


21 Informant


Winifred Orrall


(Address) 10 Floyd St. 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)


14/25 11


(Official Designation)


(Date of Issue of Permit)


V.B. 1


CTIONS OR ERTIFICATE


iving F DEATH : enter an one or each ) and (c)


s not mean of dying, art failure, c. It means or compli- ich caused


s, if any, ve rise to use (a), ie under- use last.


ons contrib- ath but not he terminal lition given


Chapter 137, 54. requires s to print or cause or f death on ificates, and 48, Acts of uires Physi- print or type er signature.


M. Traunstein, Jr , M. D


(Signed)


M. D In. Traunstein for.


(PRINT OR TYPE SIGNATURE)


(Address) 73 Bartlett Rd.


Date. Oct. 24, 19 61


Winthrop 52, Mass


6 Winthrop


Winthrop


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL Oct. 27 1961


7 NAME OF


FUNERAL


DIRECTOR


Howard S Reynolds


Winthrop, Mass.


ADDRESS


Received and filed


OCT 25 1001


.. 19.


(Registrar)


(Year)


4 I HEREBY CERTIFY,


Oct. 9, 195719


to ..


That I attended deceased from


Oct. 24,


61


19


I last saw himl.alive on


October 24.


61


.. , death is said to


have occurred on the date stated above, at


4:00 a. m.


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


Carcinoma of prostate


(a)


Due To (b)


Due To (c)


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed?


no


What test confirmed diagnosis?


Clinical & laboratory


5 Was disease or injury in any way related to occupation of deceased? If so, specify


.. no ..


PARENTS


St


(If nonresident, give city or town and State)


10 SINGLE


(write the word)


3 DATE OF


DEATH


October


24,


1961


(Month)


(Day)


INTERVAL BETWEEN ONSET AND DEATH 12 yrs


28145


PLACE OF DEATH


Suffolk (County)


No. Winthrop Community Hos ital


10 Floyd Street


12


72


8


Months.


24


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RECEIVED


OF


TOWA


(IM)


MIN


CLERK


6 5


VTHROR


OCT 251961 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 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.


COPY OF CERTIFICATE OF DEATH


CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE


X


1. NAME OF


DECEASED


A. [FIRSTI


B. (MIDOLE)


J.


C. (LAST)


Sullivan


2. DATE


OF


DEATH


10/25/61


3. PLACE OF DEATH


A. COUNTY


Hillsborough


4. USUAL RESIDENCE (WNERE DECEASEO LIVEO. IF INSTITUTION: RESIDENCE


BEFORE ADMISSION.)


A. STATE


Mass.


Suffolk


B. CITY


OR


TOWN


Manchester


C. LENGTH OF


STAY (IN THIS PLACE)


C. CITY (GIVE ACTUAL TOWN OF RESIDENCE. NOT MAILING ADDRESS).


OR


TOWN


Winthrop


D. FULL NAME OF (IF NOT IN NOSPITAL OR INSTITUTION. GIVE STREET ADDRESS OR LOCATION)


HOSPITAL OR


INSTITUTION


D. STREET IIF RURAL, GIVE LOCATION)


ADDRESS


442 Belcher St.


E. IS RESIDENCE


ON FARM?


YES


NO


5. SEX


Male


6. COLOR OR RACE 7.


White


MARRIED


NEVER MARRIED


DIVORCED


WIDOWED


8. NAME OF HUSBAND OR WIFE (MAIDEN NAME IF WIFE)


Mildred F. Mccarthy


9. DATE OF BIRTH


9/7/02


10. AGE {IN TEARS


LAST BIRTHDAY)


59


IF UNOER ! YEAR MONTHS OAYS


IF UNDER 24 NRS NOURS MIN.


-


11A. USUAL OCCUPATION (KIND OF WORK


OOHE OURING MOST OF WORKING LIFE, EVEN IF RETIRED)


Salesman - Sav.


rod. Co.


INDUSTRY


12. BIRTHPLACE ICITY OR TOWN. STATE


OR FOREIGN COUNTRYI


East Boston, Mass.


13. CITIZEN OF WHAT


COUNTRY?


USA


14. FATHER'S NAME


John J. Sullivan


15. MOTHER'S MAIDEN NAME


Mary A. Green


16. WAS DECEASED EVER IN U.S. ARMED FORCES?|17. SOC. SEC. NO.


(YES. NO. OR UNKNOWN) | [IF YES, GIVE WAR OR DATES OF SERVICE)


No


18A. INFORMANT


John Sullivan


18B. ADDRESS


42 Belcher St.


Winthrop, Mass.


19. CAUSE OF DEATH (ENTER ONLT ONE CAUSE PER LINE FOR (A). (Bl. ANO (CI


PART I DEATH WAS CAUSED BY,


Coronary thrombosis


IMMEDIATE CAUSE (AI


to


and last saw


alive on


22. I attended the deceased from


Death occured at


6:15P.


im on the date stated above; and to the best of my knowledge, from the causes stated.


23A. SIGNATURE


L. D. Lavoie, Med. Ref.


23B. ADDRESS


Manchester, N. H.


23C. OATE SIGNED


10/25/61


24A. BURIALXXCREMATION


ENTOMBMENT


REMOVAL


248. DATE


10/30/61 Winthrop Cem.


24D. LOCATION (CITT. TOWN. OR COUNTY)


Winthrop, Mass.


IF ENTOMBED


24E. PLACE OF BURIAL


(NAME OF CEMETERY)


LOCATION (CITY. TOWN. COUNTT) ( STATE)


DATE


25. FUNERAL DIRECTOR'S SIGNATURE


A. Maley, Winthrop, Mass.


ADDRESS


COUNTERSIGNED - AGENT (CITY BO. OF HEALTH) DATE


James J. Powers, M.D. 10/27/61


DATE REC'D BY TOWN OR CITY CLERK


10/27/61


CLERK'S OWN SIGNATURE


M. J. Quinn


CLERK OF


Manchester, N. H.


0 19


A true copy, Attest:


Clerk of.


Manchester


Dated.


11/8/ ,61


V$ 17


C.O.22621-6-60-10M


AV.B.V


207


845


TOWN OR CITY


CLERK'S NO.


(MONTN)


(DAY)


{TEARI


(TYPE OR PRINT)


William


24 c. NAME OF CEMETERY OR


CREMATORY


(STATE)


(DEGREE OR TITLE)


INTERVAL BETWEEN


ONSET AND DEATH


Sudden


her


him


118. KIND OF BUSINESS OR


Sacred Heart Hospital


TO!


12.


1


1


6. 5


NOV -91981 MY


X PLACE OF DEATH


Suffolk County ) LesTore 17-4-11


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.


MOUNTS CONVALESCENT HOMESt. I give its NAMI No. FRANCES BONNEY


2 FULL NAME


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


189 Brooks St.


.St.


East.Poston


(If nonresident, give city or town and State)


days. In place of residence


.. years.


months ..


days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


OCTOBER 28,


1961


(Year)


(Month)


(Day)


4 I HEREBY CERTIFY,


That I attended deceased from


FEB8


, 1956, to OCT 28,


19.61


I last saw hA Qalive on


OCT 28


1961, death is said to


have occurred on the date stated above, at


12 45 P.m.


INTERVAL


BETWEEN


ONSET ANO


DEATH


11 IF STILLBORN, enter that fact here.


12


76


24 bes


AGE


Years.


Months ..


Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


housework


14 Industry


or Business :


own home


15 Social Security No.


Gloucester


SIGNIFICANT


CONDITIONS


OTHER


PAGETS DISEASE


OFBONES


20 YRS


Was autopsy performed ?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased1/0. If so, specify


(Signed)


a.M. Caplan M. D. A. M. CAPLAN/ MO (PRINT OR TYPE SIGNATURE)


(Address) 186 PRINCETON ST 10-28 1961


FAST BOSTON MASS


Everett.


Place of Burial or Cremation


DATE OF BURIAL


Nov. 7(City or Town) 61


19


7 NAME OF


FUNERAL DIRECTOR


Frederick J. Magrath


ADDRESS


325 Chelsea St. E. Foston


Received and filed OCT 31 1961 19


(Registrar)


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


NovaScotia


19 MAIDEN NAME


OF MOTHER


Mary A. Forbes


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


"Nova Scotia


Gladys Dowe


21


Informant


(Address)


189 Frooks St. E. Boston


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 of other)


10/31/6/


(Date of Issue of Permit)


.


R-301A 1


CTIONS R ERTIFICATE


ving F DEATH enter an one or each ) and (c)


not mean of dying, art failure, ;. It means or compli- ich caused


, if any, e rise to use (a), e under- use last.


ns contrib- th but not he terminal ition given


apter 137, . requires to print or cause or death on cates, and Acts of res Physi- nt or type signature.


0-925686


(Official Designation)


V


Registered No.


208


[(If death occurred in a hospital or institution,


PHYSICIAN - IMPORTANT


f(Was deceased a


U. S. War Veteran,


no


[if so specify WAR)


(a) Residence. No.


(Usual place of abode)


Length of stay: In place of death 4


years 10 months 21


8 SEX


female


9 COLOR


white


10 SINGLE


(write the word)


MARRIED


WIDOWERowed


or DIVORCED


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


Calvin Zonney


(Husband's name in full)


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


CARDIAC FAILURE


MYOCARDITIS


Due


(b)


ARTERIOSCLEROSE


HEART DISEASE


10YRS


Due To


BRONCHOPNEUMONIA


(c)


24 HRS


16 BIRTHPLACE (City)


(State or country)


Mass


17 NAME OF


FATHER


Ruben Cahoon


6 Woodlawn


X


WT


(Kind of work done during most of working life)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE.


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


1


OCT 33.1961 TR


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice:


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.


X


PLACE OF DEATH


(County) Winthrop (City or Town)


No.


117" Share


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


STANDARD CERTIFICATE OF DEATH


Registered No.


209


Drive


[(If death occurred in a hospital or institution,


St. ¿ give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


f(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.)


11705 here


(a) Residence. No.


(Usual place of abode)


Length of stay: In place of death.


23


years


.. months ...........


.days. In place of residence.


years.


.. months .....


......


... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


Cetober


28


1961


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


19


19 to.


I last saw h ........ alive on


19 ...


... , death is said to


have occurred on the date stated above, at 2.20 P.m.


INTERVAL BETWEEN ONSET AND DEATH


DEATH WAS CAUSED BY: IMMEDIATE CAUSE (a) Death brinsand


bly due to


probably natural causes Due To (b) acute coronary conclusion


que to hypertensive Coronary artery hearts


OTHER


SIGNIFICANT


Winthrop Board of CONDITIONS Charles Liberty 3.


Was autopsy performed ?


What test confirmed diagnosis?


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


(Signed) CHARLES LIBERMAN MID.


(Address)


(PRINT OR TYPE SIGNATURE) Winthrop, Mass Date 10/28/1961


Tifereta Des of Winthrop ver It 6


(City or Town)


DATE OF BURIAL


7 NAME OF FUNERAL DIRECTOR ERF tuno. 1-Service are


ADDRESS Washun, the care Elulsin


Received and filed


19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


11


9 COLOR


10 SINGLE


MARRIED


WIDOWED Married


or DIVORCED


10a If married, widowed, or divorced Lena Weinstein 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 64 Years


Months ...


.......


.Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Watch Maker


(Kind of work done during most of working life)


14 Industry


or Business :


Jewelry Stare


15 Social Security No. Net /Amo-lobyly


016-26-957


16 BIRTHPLACE (City)


(State or country)


Russia.


17 NAME OF


FATHER


Levy 'LASER


18 BIRTHPLACE OF


FATHER (City)


(State or country)


ThisSia


19 MAIDEN NAME


OF MOTHER


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


7


-0155ml


21


Informant


(Address)


Damon Rd. Medford


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


(Signature of Agent of Board of Health or other)


12+16/


(Official Designation)


(Date of Issue of Permit) /


1


Released by Click of


CTIONS OR ERTIFICATE iving F DEATH enter an one or each ) and (c)


s not mean of dying, art failure, c. It means or compli- ich caused


, if any, re rise to use (a), se under- use last.


ons contrib- ith but not he terminal ition given


.


hapter 137, 4. requires to print or cause death on icates. and 1, Acts of res Physi- nt or type signature.


30 1961


59-925686


EPIT


2 FULL NAME Leonard


G


Glaser


Drive


.St.


(If nonresident, give city or town and State)


23


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


R-301A H 1


PARENTS


DR. GEORGE GLASER (SON)


Place of Burial or Cremation


Oct, 29


1961


isease


Health


(write the word)


A


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


TO.


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


٠٧.


6 2M


RULES OF PRACTICE OCT 301961 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 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.


1.


L


X


PLACE OF DEATH


Suffock (Cour y)


CINSEPETIT


Winthrop (City or Town)


NOWinthrop Community Hospital


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.


Registered No.


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


PHYSICIAN - IMPORTANT


[ (Was deceased a ¿U. S. War Veteran,


(if so specify WAR)


.....


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


(a) Residence. No. ... 83 Woodside Av. Winthrop. Mass .. St.


(Usual place of abode )


Length of stay: In place of death ..


years .


27


.days.


In place of residence ..


1 7 years.


.. months.


days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


f -male


9 COLOR


urcite


10 SINGLE


(write the word).


MARRIED


widowed


WIDOWED


or DIVORCED


4 I HEREBY CERTIFY,


That I attended deceased from


10-4-61


19 ... 6.1, to.


10-31


1961.


I last saw h ........ alive on 10-31-1961


19.


death is said to


have occurred on the date stated above, at


6 321 m.


INTERVAL


BETWEEN


ONSET AND


DEATH


11 IF STILLBORN, enter that fact here.


AGE ... £.1.Years .......


07


.. Months


Days


If under 24 hours


Hours.


.. Minutes


Due To


(b)


Hypertensive Heart disease


Due To


(c)


Cerebral Hemorrhage


OTHER


SIGNIFICANT


Left Hemiplegia


CONDITIONS


Was autopsy performed?


No


What test confirmed diagnosis?


5 Was disease or injury in any way related to occupation of deceased? If so, specify


NO


ar Caplan


M. D


(Signed) A "NICAPLAN MI) "PRINT OR TYPE SIGNATURE) (Address) 180 PRINCELONS Date 10-31 1961 FAST BOSTON MASS


6


Place of Burial or Cremation (City or Town)


DATE OF BURIAL


19


7 NAME OF


FUNERAL DIRECTOR


alfred B. Marche


ADDRESS


......


Received and filed


11-2-1001


(Registrar)


PARENTS


18 BIRTHPLACE OF


FATHER (City)


County cork


(State or country)


Treland


19 MAIDEN NAME


OF MOTHER


Tapparet Kelley


20 BIRTHPLACE OF


Boston


MOTHER (City)


(State or country)


Lessachusetts


21 Informant (Address)


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


(Signature of Agent of Board of Health or other)


11/5/6/


(Official Designation)


(Date of Issue of Permit)


T V. BV


CTIONS R ERTIFICATE


iving F DEATH : enter an one or each ) and (c)


not meon of dying, art foilure, c. It meons or compli- ich coused


, if ony, ve rise to use (o), te under- use last.


ons contrib- ith but not he terminol ition given


Chapter 137, 54. requires s to print or cause or death on ificates, and 18, Acts of lires Physi- rint or type er signature.


28145


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


Charles Edwin Theall


(Husband's name in full)


13 Usual


Occupation :


houserice


(Kind of work done during most of working life)


3 Weeks4 Industry


own home


or Business :


3 . WeeksSocial Security No. .......


032-03-3939-D


16 BIRTHPLACE (City) (State or country) essobreatto


Boston


17 NAME OF


FATHER


Patrick Creency


0


Agnes


Theall


2 FULL NAME


Mary


(First Name)


( Middle Name)


(Last Name)


(If nonresident, give city or town and State)


3 DATE OF


DEATH


Oct.31 ...... 1961


(Month)


(Day)


(Year)


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Congestive ........ Heart Failure


R-301A 1


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER.


5


NOV - 21961 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.


PLACE OF DEATH


Suffolk (County)


Brighton ((Vy or Town) St. Elizabeth's Hospital No.


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD


CERTIFICATE OF DEATH


211 To be filed for burial permit with Board of Health of it. Apeni 028.3.2


Registered No.


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


PHYSICIAN - IMPORTANT


2 FULL NAME Baby Boy ( First Name) ( Middle Name) ( Last Name)


Williams


[ { Was deceased a


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




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