USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 5
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(a) Residence. No.
(Usual place of abode)
Length of stay:
In place of death.
.. years
.months.
days. In place of residence.
1.1.f@rs
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
January 25, 1961
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY,
That I attended deceased from
Oct 14
19
to
25
JAN 25
61
I last saw h Chalive on
1/25/61
19
death is said to
have occurred on the date stated above, at
10 45 Am.
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
ACUTE PULMONARY EDEMA
INTERVAL
11 IF STILLBORN, enter that fact here.
BETWEEN
ONSET AND
DEATH
3 HRS.
Years
.Months.
.Days
If under 24 hours
Hours.
Minutes
Due To
(b)
MYOCARDIAL DISEASE
3 YRS.
Due To
(c)
ARTERIOSCLEROTIC HEART
DIS. WIN CONGESTIVE FAILURE
3YRS
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)
Myson n. King
M. D
MYRON N. KING M.D
222 PLPRINT OR TYPE SIGNATURE)
(Address)
WINTHROP MAS Date
1/25 1961
HolyCross
Malden
6
Place of Burial or Cremation
(City or Town) January 27
19 61
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS Winthrop .... Mass
Received and filed
JAN 2-6-1961
...... 19
(Registrar)
PARENTS
18 BIRTHPLACE OF
FATHER (City) (State or country) Ireland
19 MAIDEN NAME
OF MOTHER
Susan Sheekey
20 BIRTHPLACE OF MOTHER (City) (State or country) Ireland
21 Fred Culkeen
Informant (Address) 28 Schofield Dr .. Newton
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: gulphs serienne (Signature of Agent of Board of Health or other)
1/26/6/
(Official Designation)
(Date of Issue of Hermit)
RUCTIONS FOR CERTIFICATE
giving OF DEATH
not enter than one for each (b) and (c)
oes not mean e of dying, heart failure, etc. It means se, or compli- which caused
ons, if any, gave rise to cause (a), the under- cause last.
itions contrib- death but not the terminal ondition given
- Chapter 137, 1954, requires ans to print or he cause or of death on ertificates, and : 48. Acts of equires Physi- o print or type nder signature.
11.C
0-928145
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DMareded
10a If married, widoreda dicuikeen
HUSBAND of
(Give maiden name of wife in full)
12
AGE 63
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry
or Business : ...
Sales lady
Raymonds
15 Social Security No.
011-24-6846
16 BIRTHPLACE (City)
(State or country)
Mass
Winthrop.
17 NAME OF
FATHER
Patrick Sheerin
DATE OF BURIAL
210 Main Street
No ..
(First Name)
(Middle Name)
(Last Name)
St.
( If nonresident, give city or town and State)
1 R-301A 1
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 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.
M R-301A 1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
No.
15 Siren Street
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.
20
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Mary (Haggerston) Lougee
(If deceased is a married, widowed or divorced woman, give also maiden name.)
15 Siren Street
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
years ..
......
.. months .............. days. In place of residence ..
9.1
.. years
Omonths .... 28.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
January 25, 1961
(Month)
(Day)
(Year)
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCEWidow
10a If married, widowed, or divorced
HUSBAND of
Edwin Lougee
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
=
12
.... 91 Years.
0
Months .... 28 .. 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.
None
Winthrop
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
Alexander Haggerston
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass
Watertown
19 MAIDEN NAME
OF MOTHER
Louisa Tewksbury
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass
Winthrop
(Address) Winthrop 52, Mass
6 Winthrop
Winthrop
Place of Burial or Cremation
(Cjty or Town)
DATE OF BURIAL
Jan. 28
19
61
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
Winthrop Mass
ADDRESS
Received and filed JAN-3-0-4961 19
(Registrar)
PARENTS
21 Eva Murray
Informant
(Address)
90 Terrace Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit" was issued: Ralph E
Signature of Agent of Board of Health or other)
4,0
1/27/6/
(Official Designation) (Date of Issue of Permit)
V.A.V
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, , etc. It means ase, or compli- which caused
tions, if any, gave rise to cause (a), the under- 8
cause last.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Hypertrophic arthritis
12 yrs
Was autopsy performed ?
no
What test confirmed diagnosis ?
Clinical & laboratory
5 Was disease or injury in any way related to occupation of deceased ? nQ. If so, specify-
, M. Traunstein, Jr., M. D.
(Signed)
M. D.
M. Traunstein, Jr., M. D.
(PRINT OR, TYPE SIGNATURE)
73 Bartlett Rd
Date.
January26, 61
61
I last saw h.C.
eralive on
January 25, 1961
death is said to
have occurred on the date stated above, at
9:20 p. m.
INTERVAL
BETWEEN
ONSET AND
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Arteriosclerotic and hypertensive DEATH
heart disease
8 yr
Due ToGeneralized arteriosclerosis (b)
10 yrs
(write the word)
4 I HEREBY CERTIFY,
That I attended deceased from
.. January ...... 7 , , 152
to
January 25,
19.
(Was deceased a U. S. War Veteran, [if so specify WAR)
(a) Residence. No.
(Usual place of abode)
50
-11-59-926662
W.c.
- Chapter 137, 1954, requires ans to print or he cause or of death on ertificates, and 48, Acts of quires Physi- print or type der signature.
editions contrib- death but not to the terminal condition given
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE TOW
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
0
C.
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.
15M-6-60-928241
INSET PLACE OF DELIVERY No. Winthrop Community Hospital
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. 21
(If death occurred in a hospital or institution, give its NAME instead of street and number)
3 DATE OF DELIVERY
1 26
61'
(Month )
(Day )
(Year)
4 SEX
Male .. .. Female .. Undetermined
5 COLOR (if
determined) .Al.
6 THIS BIRTH (Check one) Single/. Twin . Triplet
7 IF MULTIPLE BIRTH, BORN : 1 st. .2nd. .3rd
FATHER
MOTHER
MAIDEN NAME Antonetta Camiolo PRESENT NAMEAntonetta Foti
9 RESIDENCE, NO.164 Cottage STREET
CITY OR TOWN East Boston
STATE Mass
15 RESIDENCE, NO. 164 Cottage. CITY OR TOWNEast Boston STATE
STREET Mass.
10 COLOR OR
RACE.
White
11 AGE AT TIME OF THIS DELIVERY 38 (Years)
16 COLORIRRite RACE
17 AGE AT TIME OF2 8 THIS DELIVERY
(Years)
12 PLACE OF
BIRTH
Boston (City or Town )
Mass
18 PLACE OF BIRTH Boston (City or Town)
Mass
(State or country )
Pressman
19 INFORMANT Mother
20 PREVIOUS DELIVERIES TO MOTHER ( Do not include this fetus) Three
(a) How many children are now living ? 3
(b) How many children were born alive ut are now dead ?
(c) How many previous fetal deaths of ANY gestation age ?
0
21 LENGTH OF PREGNANCY 26 .completed weeks
22 WEIGHT OF FETUS 2 Lb. 4 Oz
23 WHEN DID FETUS DIE? Before Labor During Labor or Delivery X
24 AUTOPSY
Yes .
No
X
25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Premature scarring of placenta Due To (b) Premature seperation and Due To (c) bleeding causing insufficien blood supply to fetus OTHER SIGNIFIC CONDITIONS
26 HOLY CROSS Place of Burial or Cremation
DATE OF BURIAL JAN. 27,
MALDEN (City or Town) 19
27 NAME OF
FUNERAL DIRECTOR//PIETROKVAZZA ADDRESS / HENRY ST, EAST BOSTON
Received and filed
JAN 26 1961
.19.
A TRUE COPY ATTEST :
I HEREBY CERTIFY that this delivery occurred on the date stated above at
9. 55 nAMAnd product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner : G. M. Caplan M.D.
A "PRAT Hapkan NATURE)
Address East Boston
Date 1/26/961
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or, transit permit was issued :
Malkh E. Seriaum (Signature of Agent of Board of Health or other )
4.0. 1/26/6/ (Official Designation ; (Date of Issue of Permit)
X
In giving CAUSE OF TAL DEATH do not enter more 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. ) al and/or ma- nal conditions, ny, which gave ;e to above se (a), stating · underlying ise last.
naditions of fetus mother which y have contrib ed to fetal ith, but, in so as is known, re not related cause given (a).
5 +5
1
ORM R-304 X Suffolk Winthrop (City or Town )
2 NAME OF FETUS
(if given )
Baby Boy Foti
St.
Registrar
Grams )
Unknown
(or
(State or country )
13 OCCUPATION
8 FULL NAME Ralph Foti
OF TOW
OFFICE DA
11 12 1
10
FETAL DEATH
10
18
HROP.
EXTRACTS OF CERTAIN SECTIONS OF AS AMENDED OR ADDED BY CHAPTER 48.
ACTS OF 1960.
Section 2A. "Examination of Jobb 161961 turns 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.
RM R-303 A 1
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF
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
PLACE OF DEATH
SUFFOLK (County) WINTHRO.P. (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.
22
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) No. Winthrop Police Haatrs.
2 FULL NAME
HAROLDE. ..... FRENCH
(First Name)
(Middle Name)
(Last Name)
U. S. War Veteran,
(if so specify WAR)
NO
( If deceased is a married, widowed or divorced woman, give also maiden name.)
183 Winthrop St.
St.
Winthrop, Mass
(a) Residence. No.
( Usual place of abode)
Length of stay :
In place of death
.years.
months.
1
days .
In place of residence
69
.years
-
.. months ..
-
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
January
28.
1961
(Month)
(Day)
(Year)
9 SEX
Male
10 COLOR
White
(write the word)
11 SINGLE
MARRIED
SINGLE
WIDOWED
or DIVORCED MARRIED
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.) Coronary occlusion; Acutemyocardial ..... infarction
lla If married, widowed or divoted Dempsey
HUSBAND of
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
A(, 69
Years ...
Months.
-
Days
If under 24 hours
Hours
Minutes
14 Usual
Occupation':
Costable
(Kind of work done during most of working life)
15 Industry
or Business :
......
Town of Winthrop
16 Social Security No.
028-09-7472
17. BIRTHPLACE (City)
....
Winthrop
(State or country)
Mass.
18 NAME OF FATHER Ora French
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Wok wen
not Known
20 MAIDEN NAME Mary J. Sawyer OF MOTHER
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass
Boston
Mrs. Anna French
22
Informant
(Address)
183 Wintrop St. Winthrop Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E. Nicianna
(Signature of Agens of Board of Health or other)
yam30/61
(Official Designation) "(Date of Issue of Permit)
(Registrar)
PARENTS
6 Was disease or injury in any way related to occupation of deceased?
If so, Specif
(Signed) ....... Michael A. Luongo, NO.
(Print or Type Signature) (Address) Boston, Mass Date Jan. 29,61
7
Winthrop, Cemetary,
Winthrop
Place of Burial, or Cremation.
(City or Towns
DATE OF BURIAL Feb. 1. 1961 19
8 NAME OF
FUNERAL DIRECTOR
Maurice W. Kirby
ADDRESS 210 Winthrop St. Winthrop, Mas
Received and filed
JAN 30-1961
19
PHYSICIAN - IMPORTANT
[(Was deceased a
(If nonresident, give city or town and State)
(Give maiden name of wifeIn full)
5 Accident, suicide, or homicide (specify)
Date and hour of injury
19
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 ?
Manner of (Specify type of place)
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed?
No
§§ 44-48.
HO laHA end of
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 obsestance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poison) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
PLACE OF DEATH
Suffolk (County)
INSTITUTIO
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.
23
Winthrop Community Hospital
No.
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
50 Bates Avenue
St.
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years.
months.
4
.days. In place of residence
60
.years ..
months.
......
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
/
24
1961
(Year)
(Month)
(Day)
That I attended deceased from
61
I last saw h, ALalive on
1/29
16/
death is said to
have occurred on the date stated above, at
6.30Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
BRONCHO-PNEUMONIA
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
3 DAYS
11 IF STILLBORN, enter that fact here.
88
12
AGE
.. 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 :
Own Home
15 Social Security No.
Dorchester
16 BIRTHPLACE (City) (State or country) Mass
17 NAME OF
FATHER
John Hurley
18 BIRTHPLACE OF
Frederickton
FATHER (City)
(State or country)
New Brunswick
19 MAIDEN NAME
OF MOTHER
Mary McGrath
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Frederickton
New Brunswick
Helan A. Sullivan
21
Informant
(Address)
50 Bates Ave., Winthrop
I HEREBY CERTIFY tbat a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Malkh E Percanne (Signature o/ Agent gi Board of Health or other)
1
/
38/6/
Received and filed JAN 30 1961
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDEtowed
(write the word)
10a If married, widowed, or divorced
HUSBAND of
Edward F. Sullivan
(or) WIFE of
(Husband's name in full)
Due To
·ARTERIO-SCLEROTIC
(b)
HEART DISEASE
jogar
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
0
What test confirmed diagnosis ?
0
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
twee D' Regan
M. D.
FRED O' PEGAN AMID
(PRINT OR TYPE SIGNATURE)
(Address) 113 PLEASANTST
Date. 1/29 1961
6 Winthrop Cemetery Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL February ..... 1 19.61
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Arthur J. O'Maley
Winthrop Mass
40.
(Official Designation)
(Date of Issue of Permity
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, z, etc. It means lease, 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- o print or type der signature.
8-11-59-926662
M R-301A 1
Mary C ( Hurley) Sullivan
[(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)
(a) Residence. No.
(Usual place of abode)
4 I HEREBY CERTIFY,
Deci
19.60
to
1/29
PARENTS
To be filed for burial permit with Board of Health or its Agent.
SPACE FOR ADDITIONAL INFORMATION -
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER YTHROP
JAN .3.01961-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.
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