USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 6
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(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) therinal, 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)
ANSE PE TTU
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.
21
No.
WinthropConvelecent .Home
.........
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. 24Spring ..... St.Mansfield, Mass ...... .St. Winthrop Mass
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years ..
1.months .... L.L.days. In place of residence.
5
... years .......... 5 months ..... 8 ..... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
January
30
19.61
(Month)
(Day)
(Year)
4 Į
HEREBY CERTIFY,
That I attended deceased from
NOVEMBER 23, 1960, t
JANUARY 30
1961
I last saw h ........ alive on
JANUARY 29, 1961, death is said to
have occurred on the date stated above, at
3:00 A.
m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
CEREBRAL HEMORRHAGE
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
7 DAYS
11 IF STILLBORN, enter that fact here.
12
AGE ... 6.6 Years.
4 ..... Months ..... 2.
,Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
housewife
(Kind of work done during most of working life)
14 Industry
own home
15 Social Security No.
none
16 BIRTHPLACE (City)
(State or country)
Connecticut
17 NAME OF
FATHER
Herman Mugler
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Germany
19 MAIDEN NAME
OF MOTHER
Hermine Mommendey
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Germany
Informant
Hermine G. Tixeira
(Address)
24 Spring St. Mansfield
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Mass ...
Habphe. Livecem
(Signature of Agent of Board of Health or other) peb. 1,1961
-
(Official Designation)
(Date of Issue of Permit)
X
Pemame
9
COLOR
White
10 SINGLE
(write the word)
MARRIED
Widowed
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Charles A. Crane
(Husband's name in full)
Due To
HYPERTENSION
(b)
10YRS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? e. If so, specify
(Signed)
Dorothy Cheney appleton
M. D.
DOROTHY/ Cheney APPLETON M.D
(PRINT OR TYPE SIGNATURE)
Date Jan 30 1961 (Address) 197 Woodardes are. Maga
6
Winthrop Cemetery
Winthrop, Mass
Place of Burial or Cremation (City or Town) DATE OF BURIAL ... February 1.1967 19
7 NAME OF
FUNERAL DIRECTOR
alfred 13 March
ADDRESS 174 Winthrop St. Winthrop
Received and filed 19
(Registrar)
PARENTS
5-59-925686
I R-301A 1
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
pes not mean of dying, e heart failure, etc. It means e, or compli- which caused
ons, if any, gave rise to cause (a), the under- cause last.
itions contrib- death but not the terminal ndition given
Chapter 137, 954. requires is to print or cause or f death on tificates, and 48, Acts of uires Physi- print or type ler signature.
-
14-1-6
Winthrop (City or Town)
S(If death occurred in a hospital or institution,
2 FULL NAME.
Hermine J. Crane ( Mugler)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Registered No.
Meridan
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE IF TOW
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT 6,
SERVICE NUMBER
FEB -21961 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.
OUT - OF - TOWN,
25
To be filed for burial permit with Board of Health or its 00338
Registered No.
[(If death occurred in a hospital or institution,
... St. Į give its NAME instead of street and number)
Francis. E. Lynch
(If deceased is a married, widowed or divorced woman, give also maiden name.)
168 Bartlett
Road
St
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years .............. months.
yr. In place of residence.
45€
years.
.......
months .............. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED ST&wg)
WIDOWED
or DIVORCED
4 I HEREBY CERTIFY.
1- 11
61
19.
to ..
1- 1/
1961
I last saw h !..... alive on
/-
11
19.
61
death is said to
have occurred on the date stated above, at
8:00 P.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
chronic Duodenal uker
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
AGE.
6.7 Years.
Months .....
.Days
If under 24 hours
.Hours .............. Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry
or Business :
Finance U.S. Government
15 Social Security No.
NONE
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
John E. Lynch
Boston
18 BIRTHPLACE OF
FATHER (City)
(State or country) Massachusetts
19 MAIDEN NAME
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
(Address). Eliz. Hosp. Date 1-12 1961
Holy Cross Cemetery Malden
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL January 14, 1951
7 NAME OF
Arthur J. O Maley
FUNERAL DIRECTOR
79Atlantic St. Winthrop
ADDRESS
ne apy filed CJAMILI 1901 .......... 19.
(Registrar)
PARENTS
21 Informant John E. Lynch, Jr., ss) 168 Bartlett Rd Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Jacqueline Caney (Signature/of Agent of Board of Health or other) A 00335 1-12-61
(Official Designation) (Date of Issue of Permit)
V
RM R-301A 1
NSTRUCTIONS FOR CAL CERTIFICATE
In giving SE OF DEATH do not enter ore than one iuse for each a), (b) and (c)
s does not meon mode of dying, os heart foilure. tio, etc. It means isease, or compli- which coused S
A
541.
ditions, if any, ch gove rise to ve cause (a), ing the under. & cause last.
onditions contrib- to death but not i to the terminal condition given
: :- Chapter 137. f 1954. requires cians to print or the cause or of death on certificates, and er 48, Acts of requires Physi- to print of type under signature. 1.0
B 20 1961
IN-11-59-926662
PLACE OF DEATH
Suffolk County) Brighton (Chy or Town)
CINSIMIT
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
St. Elizabeth's Hosp.
No.
PHYSICIAN - IMPORTANT
[(Was deceased a
U. S. War Veteran,
[if so specify WAR)
WW#1
' 3 DATE OF
DEATH
Jan.
1961
(Month)
(Day)
(Year)
'That I attended deceased from
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Due
(b)
à massive hemorrhage
Due To
Myocardial infarct, recent
(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
Boston
(Signed)
John P. Santos
M. 1).
OF MOTHER
Mary A. Flynn
John P. Santos, M.D.
(PRINT OR TYPE SIGNATURE)
(a) Residence. No.
...
(Usual place of abode)
8 hrs.
2 FULL NAME
-
REDE YED
TOW:
OF
11.12
1-
0
. ERK
-
00
5
6
A'IN
THROP
FEB 2 01961 AM
PLACE OF DEATH
SUFFOLK BOSTON
(C'ity or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
UL- OF-LOW 26
To be filed for burial permit with Board of Health or its Agent. 00571
Registered No.
S(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,
None
lif to specify WAR)
(a) Residence. No. 184 Somerset Avenue
(1'sual place of abode )
St. Winthrop, Massachusetts
(If nonresident, give city or lown and State)
Length of stay : In place of death.
.... years.
months
1
1
days. In place of residence
years
.months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL. AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
MARRIED
WIDOWED &A,
or DIVORCED
4THEREBY CERTIFY
That Feattended deceased from
January 15 . 1.61
January 16
10a Il married, wiJarier ForBaumeister HUSBAND of (Olive maken name of wife In full)
(or) WIFE of
(Husband's name in full)
IT IF STILLHORN, enter that fact here
12
54
mts
٧٥are
5
Monthe
8
If under 24 hours
Tottr .......... Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Marine Hardware
15 Social Security No.
025-01-4418
16 BIRTHPLACE (City)
(State or country)
Boston,
Ma 88
17 NAME OF
FATHER
Thomas
0, Connor
18 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Rosella Doherty"
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston
21
Informant
(Address)
Mrs Jane O'Connor
184 Somerset Ave, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death wu błed with me BEFORE the burial or transit permit was lasued:
FUNERAL DIRECTOR ADDRESS ... 147 Winthrop St, Winthrop
JAN 13 1961
19
Received And filed Charles 91 In a curatil
PARENTS
Winthrop
Winthrop Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL. ... Jan.19 61
19.
7 NAME OF
Ernest P Caggiano
M. I).
(Address)
Ass't. Dir., Mass. Gen'l. Hoap. Date Jan. 16 19 61
16 yrs
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 ao, specify
(Signed) Charles L. Clay, M. D. (PRINT OR TYPE SIGNATURE)
٧٢٤
Due To
LAENNEC'S CIRRHOSIS
(c)
(Month)
(Day)
(Year)
.
YHlast saw himalive on.
January 16. 19 61, death is said to
have occurred on the date stated above, at .4:00 .p ...... m.
INTERVAL
BETWEEN
DNSET AND
DEATH
DEATH WAS CAUSED BYI IMMEDIATE CAUSE
(a)
Aspiration of Blood into
LUNGS
Due To
ESOPHAGEAL VARICES
(b)
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
Does not mean e of dying, heart failure. etc. It means so, or complt. which caused
6
ons, if any, gave rise to cause (g), the under. cause tast.
itions contrib. death but not the terminal ondition given
Chapter 137, 954. requires is to print or cause or . t death on tificates, and 48, Acts of uires Physl. print or type R6 196 Director use only :K Ink. M.C ·
59-925686
I R-301A 1
No.
MASSACHUSETTS GENERAL HOSPITAL
2 FULL NAME .. Thomas .... R ..... O .!. Connor.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
3 DATE OF
DEATH
January
16
1961
10 SINGLE
MATY 1ea
(Offelal Designation) (Data of Issue of Parmit)
(Signature of Agent of Board of Health or other)
A 00 429 1-18-65
VIV
Machine Operetor
TOW!
.5
MAR -61961 AM
PLACE OF DEATH
Suffolk ...
Boston
(('ity or Town)
ST. ELIZABETH'S HOSPITAL Antonette Famie FETTINE ANTOINETTE
[(If death occurred in a hospital or institution,
St. [ give its NAME instead of street and number)
2 FULL NAN
(If deceased is a married, widowed or divorced woman, give alar maiden name.)
24 TILESTON
ROAD
St.
WINTHROP
(If nonresident, give city or town and State)
length of stav · In place of death. YPAT4
months days In place of residence
14
. years ....
months
.days.
MEDICAL CERTIFICATE OF DEATII
J DATE OF
DEATH
JANUARY (Month)
20 1961
(Day) 1 (Year)
TERENY
CERTIFY
That
Allended der enmed from
JAN .10 1 19. 10 JAN. 20
1961
I last ARW halive on JAN 20
10
C. death is said to
have occurred on the date stated above, at 6:05 A.m.
INTERVAL BETWEEN ANSET AND
F DEATH
71
If under 24 hours
.. Hours .............. Minutes
13 Uqual
Occupation :
Housewife
(Kind of work done during most of working life)
t4 Industry
or Business :
At Home
15 Social Security No.
...
NINE
16 BIRTHPLACE (City)
(State or country)
Italy
17 NAME OF
FATHER
Antonia Balerno
18 HIRTHPLACE OF
FATHER (City)
(State or country)
Italy
19 MAIDEN NAME OF MOTHER Marie Conti
20 BIRTHPLACE OF MOTHER (City) (State or country) Italy
21 Ur Joseph A Famiglietti
Informant
(Address)
Court Rd, Winthrop Mass
HEREBY CERTIFY they a satisfactory standard certificate of death word with me BEFORE the burial or transn permit was Issued:
(Signature of Agent of Board of Health or other)
Received and filed
Ernest P Caggiano 147 Winthrop St Winthrop
ADDRESS ....
.......
A JAN ~ : 1961
Pie 19
(Registrar)
PARENTS
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
Robert S. Settener
.. , M. D).
(Address)
ROBERTS LETTENSY ST ELIZABETH Date 1/20
St. Michael's
Boston MáBě ......
6
Place of Burial or Cremation DATE OF BURIAL
Jan 23
19
7 NAME OF FUNERAL DIRECT
AR 6 1961
-6-59-925686
....
PERSONAL AND STATISTICAL PARTICULARS
# SEX
female
9 COLOR
white
MARRIED
WHX)WEI)
of DIVORCEDmarried
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife In full)
(or) WIFE of
Raffaele Famiglietti
(Husband's name in full)
It IF STILL BORN, enter that fact here
12
AGE
YearA
Months ..........
Days
MYOCARDIAL INFARCTION
(b)
CORONARY HEART DISEASE
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ?
NO
What test confirmed diagnosis ?
The Commonwealth of Massachusetts OUT - OF - TOWA JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
To he filed for burial permit with Hoard of Fteatth or its Agent. 00679
27
M R-301A -
ITRUCTIONS FOR AL CERTIFICATE
n gIVIng C OF DEATH not enter e than one se for each . (b) and (c)
does not mean ode of dying. heart failure. etc. It means ase, or compli. which caused
120.1
tions, il amy. gave rise to cause (a), the under- cause last.
ditions contrib. death but not to the terminal condition given
Chapter t37. 11954, requires ans to print or ne cause or of death on rtificstes, and 48. Acts of qquires Physi- print or type der signature.
n. C.
No.
PHYSICIAN - IMPORTANT
(Was deceased a
-U. S. War Veteran,
/{if so specify WAR)
(a) Residence. No. (l'sual place of abode)
10
A14418
Jon 22 ,941
(Official Designation) (Date of Issue of Hermit)
.
(City of Town) 60
10 SINGLE
(write the word)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) CONGESTIVE HEART FAILURE
Due
(c)
TO!
6
THIS
,P
MAR - G1961 AM
PLACE OF DEATH
Baptized Suffolk Minty ) Brighton (City
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
OUT - OF - TOWN 28 To br filed for burial permit with Board of Health or its Agent.
STANDARD
CERTIFICATE OF DEATH
Registered
1133
2 FULL NAME
( If deceased is @
(a) Residence. No.
150
married, wideved or divorced voman, give also maiden name.) Locust
St. Winthrop, MASS
( If nonresident
give city or town and State)
Length of stay : In place of death
........ years .............. months .............. days. In place of residence ........... years ............. month ............... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
JAN
21 1961
(Month)
(Day)
(Year)
HEREBY
CERTIFY , Thus I attended deceased from
I last saw himalive on
JAN 21
19. .... , death is said to
have occurred on the date stated above, at
m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
AtelectAsis
INTERVAL BETWEEN ONSET AND DEATH 1 hr.
Due To - (b) Prematurity
Due To (c)
........
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
170
What text confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
....
Parques Reviopen
M. D.
Desrosiers, Fregues.
(Address)
6
Mr. Bereelect (51+ kk)
Place of Burial or Cremmion.
DATE OF BURIAL
fab hot
196/1
(City or Town)
21
Informant
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burlal or transit permit was Issued:
7 NAME OF
FUNERAL DIRECTOR
20 High SK. WARHAM
ADDRESS :
Receivedand filed 1 FEB 101 /19
(Registrar)
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
Year .............
.Month ............
.. 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)
Brighton, MASJ
17 NAME OF
FATHER
Donald Colpale
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Newton, MASS
.
19 MAIDEN NAME
OF MOTHER
Claire watch
20 BIRTHPLACE OF
(State or country)
St. ELizAbellis Aspital
Buy liter
(Signature of Agent of Board of Health or other)
625
5/1/6/
(Official Designation) (Date of Issue of Permit)
INSTRUCTIONS FOR ICAL CERTIFICATE
In giving SE OF DEATH do not enter tore than one ause for each a), (b) and (e)
s does not mean mode of dying, as heart failure. tia, etc. It Means israse, or compli- which caused S
26.2.
ditions, if any, ch gave rise to ve cause (a). ing the under- « cause last.
onditions contrib. to death but not I to the terminal condition given
:- Chapter 137, f 1954, requires ians to print or the cause or of death on certificates, and r 48. Acts of requires Physt. o print or type Iltder signature.
AR 6 1961
11-11-59-926662
15 avenue
DRM R-301A
-
Saint Elizabeths Hospital No.
Baby Boy Colbak
St. ¿ give its NAME instead of street and number) No PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran, if no specify WAR)
(Usual place of abode)
4
JAN 21
19
JAN
21
19
61
PARENTS
(P'RINT, OR LOPE SIGNATURE) St. Elinbellis, Hosp Date. 1961 MOTHER (City) med ford, MASS.
West Faktury
Withinm 7. Walsh
[(If death occurred in a hospital or institution,
A TRUE COLY ATTEST:
Autres A Mackie City Registrar
. 1
MAR - 61961 AM
RM R-301A
.B .- THIS IS A IANENT RECORD. Use only TE APPROVED ck ink or black ·writer ribbon.
ISTRUCTIONS FOR CAL CERTIFICATE In giving E OF DEATH
o not enter re than one se for esch ), (b) und (c)
, does not mean ode of dying. 's heart failure. 1. etc. It means ease. or compli- which caused
204.3 tions, if any. gave rise to - cause
(.). the under- last.
0. Chapter 137, 1954, requires Mans to print or he cause or " of death on i ertidcotes. HAP. 46, 11 9 & (JAP. 114 # 45, HAP. 38 &6 R
6 1961 ial Directorı Is use only LICK Ink.
PLACE OF DEATH
SUFFOLK
------
(County)
BOSTON
......
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN
OUT - OF - TOWN
To be filled for burial permit with Board of Health or its Agent.
Registered No.
[(If death occurred in a hospital or institution, St. (give its NAME instead of street and number) -
VIRGINIA. FLISTER(Godfrey )
woman, kive aino maiden name.)
PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran, if no specify WAR) -
(a) Residence. No .. (Usual place of abode)
175 Bartlett-Rd,
St Winthrop. ..... Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death years .1 months 5 days. In piace of residence .4.4year ... 5 .... months.2.7 days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
(write the word)
female
white
10 SINGLE
MARRIED
married
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Roy .... Milton Flister
(Ilusband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE4.4 .. Years ..... 5 Months 2.7 ... 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 .....
011-01-2256
16 BIRTIIPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
George Jason Godfrey
18 BIRTHPLACE OF
FATHER (City)
Northwoodi Ctr
(State or country) New Hampshire
19 MAIDEN NAME
OF MOTHER
Winnifred Ladd
20 BIRTHPLACE OF
MOTHER (City)
Mercer
(State or country) Maine
21 Informant .. Roy M. Flister (Address) 175 Bartlett Road, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death May gled with wfe BEFORE the burial or transit permit was issued : Mariel 31 Husserive
(Signature of Agent of Board of Health or other)
595
1/31/6/
--
(Registrar)
PARENTS
7 NAME OF
FUNERAL DIRECTOR
alhet B. March
ADDRESS
174 Winthrop St. Winthrop,
Received and fled
FEB
1961
.19
SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Massachusetts General Hospital BAKER MEMORIAL
No.
...... ---
Ladd
....
2 FULL NAME ( If deceased is a married, widowed or divorced
J DATE OF
DEATII
January 28, 1961
(Month)
(DayY
(Year)
4 I HEREBY CEFTIFY. That Sattended deceased from December 22, 60. to January 28 19.6.1 Whiant saw heylive onJanuary - 28 -. 1962 . death is said to have occurred on the date stated above, at 11:05a.m.
DEATH WAS CAUSED BY! IMMEDIATE CAUSE
(a) GASTROINTESTINAL
Hemorrhage
INTERVAL
BETWEEN
ONSET AND
DEATH
UNK.
HRS
Due To
Acute Myelocytic
LeukemiA
6 Mos
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
Y.8
What test confirmed diagnosis ?... Autopsy
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
Che@low
(Address) ... A.
6
M. D.
Charles . C . M. Pioup Datel-28-
161
Winthrop Cemetery Winthrop, Mass Piace of Burial or Cremation (City or Town) DATE OF BURIALJanuary 31, 1961
29
1
(b)
Winthrop
(Officiel Designstion) (Date of Issue of Permit)
ditions contrib .- death but not to the terminal condition given
TOY
10
.....
1
0
MAR - 61961 AM
R-301A 1
PLACE OF DEATH
Suffolk (County)
FINSEPITT
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