Town of Winthrop : Record of Deaths 1961, Part 6

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 6


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


(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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