USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 2
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Virus .... infection
days
17 NAME OF
FATHER
Ist. name unknown, Brooks
Was autopsy performed ?
no
What test confirmed diagnosis ?
clinical & Laboratory 18 BIRTHPLACE OF
5 Was disease or injury in any way related to occupation of deceased ? If so, specify Andrew Nichols III
(Signed )
Andrew Nichols III
M. D.
( Address)
Hathorne, Mass.
1/9/
Date
19
Winthrop Cemetery, Winthrop
6 Place of Burial or Cremation
(City or Town) January 11, 62
19
7 NAME OF
FUNERAL DIRECTOR
Howard Reynolds
ADDRESS Winthrop, Mass.
Received and filed Fch 8 18 2 19
(Registrar of City or Town where deceased resided)
ARENTS
FATHER (City)
(State or country )
Unknown
19 MAIDEN NAME
OF MOTHERMary, maiden name unknown
20 BIRTHPLACE OF
MOTHER (City )
Unknown
Unknown
( State or country )
Informant
(Address)
21
Georgie T. Brimigion
Hathorne, Mass.
A TRUE COPY
ATTEST :
(Registrar of Cfty or Town where death occurred)
DATE FILED
January 16,
62
......
19
50M-9-59-926111
3 DATE OF DEATH (a) Due To (c) Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased CONDITIONS
January 9. 1.9.62 (Year)
8 SEX
female white
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
widowed
10a If married, widowed or divorced
XXXXX1.
Charles
McHatton
(Give maiden name of wife in full)
(or) WIFE of.
2. Fred Black
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Arteriosclerotic heart
disease
(b) Due To Generalized Arteriosclerosis
years
16 BIRTHPLACE (City)
(State or country )
connecticut
Meriden
Unknown
62ª
DATE OF BURIAL
(City or Town)
Registered No.
No.
2 FULL NAME
( Was deceased a
U. S. War Veteran,
no
(if so specify WAR.
4 I HEREBY CERTIFY,
7:05p
.. m.
MARGIN RESERVED FOR BINDING
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
X
PLACE OF DEATH
Middlesex
( County ) Cambriace
The Commonwealth of Massachusetts JOSEPH D. WARD Cambridge
SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or Town making this return)
33
6
Margyrot Fra Pontiff
2 FULL NAME.
( If deceased is a married, widowed or divorced woman, give also maiden name.) 65 Winthrop Shore Drive
(a) Residence. No ..
( Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death. ......... years .......... months. days. In place of residence .......... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
( write the word)
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorced HUSBAND of
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
80
If under 24 hours
AGE ..
Years ..
„Months .......... Days.
Hours ........ Minutes
iebrud furst
13 Usual Occupation: (Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
Sell Aver
16 BIRTHPLACE (City)
(State or country)
17 NAME OFDaniel J. Sullivan FATHER
18 BIRTHPLACE OF
FATHER (City) Traiana .
(State or country)
19 MAIDEN NAMEOrgarot Murphy OF MOTHER
Inland 20 BIRTHPLACE OF MOTHER (City) (State or country) Mirone Pontiff
21 Informant( ........ ( Address)
A TRUE COPY Maul E. Weales
ATTEST :
( Registrar of City or Town where death occurred)
DATE FILED Jan. 11, 19 52
X
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
3 DATE OF DEATH 1- (b) (Signed ) Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town OTHER SIGNIFICANT CONDITIONS resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
50M-9-59-926111
ADDRESS
Received and filed FE 19
( Registrar of City or Town where deceased resided )
PARENTS
Henry S. Robinson
M. D.
353 In ton at
· Jan.10 62
(Address) Womenville
Date
Fati iver
6 Place of Burial or Cremation January (City or Town) 62
DATE OF BURIAL
19
7 NAME OF Artur J. O'Haley
FUNERAL DIRECTOR CATHYOP, KUYT.
,
19
I last saw h ...... alive on
19 death is said to
have occurred on the date stated above, at .. m.
INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE Corebral Thrombosis with
(a) 15 parasig
Due
Hypertension
Due To Gastric Carcinoma with (c) Peritoneal metastases
Was autopsy performed ?
clinical
What test confirmed diagnosis ?
vadleny 10, 1752
( Month)
(Day)
(Year)
4 I HEREBY
CERTIFY, 62
19
That I attended deceased
Jan.
fram
§ (If death occurred in a hospital or institution. St. ¿ give its NAME instead of street and number)
(Was deceased a
U. S. War Veteran.
jf so specify WAR
ino Trop, Has's
St.
Registered No.
(City or Town) Guardian Hospital No ..
1
FORM R-302
T
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
Hurting
0:501.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
X PLACE OF DEATH
Suffolk
(County)
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.
My
Registered No.
f(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and numher)
PHYSICIAN - IMPORTANT
[(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.)
113 Pleasant Street
(a) Residence. No.
(Usual place of abode)
19
Length of stay: In place of death.
years ...
... months.
days. In place of residence.
years.
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVoarmied
10a If married, widowed, pridivorcedle Grimes HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Il IF STILLBORN, enter that fact here.
12
AGE68
Years ......
Months ..
.. Days
If under 24 hours
Hours .......
Minutes
13 Usual
Occupation :
Medical .... Doctor
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
Boston
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
William O'Regan
18 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Julia Callahan
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass
21
Informant
(Address)
F.Lucille Q'Began
II3 Pleasant St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: 1
(Signature of Agent of Board of Health or other)
1/12/10
(Official Designation)
(Date of Issue of Permit)
5-60-928145
RM R-301A 1
2958-
INSTRUCTIONS FOR CAL CERTIFICATE
In giving SE OF DEATH o not enter ore than one use for each a), (b) and (c)
does not mean mode of dying, as heart failure, ja, etc. It means sease, or compli- which caused
ditions, if any, ch gave rise to e cause (a), ing the under- cause last.
onditions contrib- to death but not to the terminal , condition given .
ote :- Chapter 137, s of 1954, requires sicians to print or the cause or es of death on h certificates, and pter 48, Acts of , requires Physi- s to print or type e under signature.
6
Holyhood Cemetery
Brookline
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL January 15 19.62
7 NAME OF
FUNERAL DIRECTOR
Arthur J O'Maley
ADDRESS Winthrop., ..... Mass ...
Received and filed
JAN-15-4962.
19
(Registrar)
PARENTS
NO
(Signed)
Charge It. Lynch
M. D
George W. Lunch
(PRINT OR TYPE SIGNATURE)
(Address)
520 Comm Are Date Jan 11 1962
Boston
Was autopsy performed?
NO
Electro Cardiogram
What test confirmed diagnosis?
INTERVAL BETWEEN ONSET AND DEA
1 hr
Due To
(b)
Coronary Sclerosis
1954
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
January
11
1962
(Year)
(Month)
(Day)
4 I HEREBY CERTIFY
April 27, 1954
to ....
January 11
1962
That I attended deceased from
I last saw himalive on
Dec
19 ... Ze./ ... , death is said to
have occurred on the date stated above, at
6:30 Am.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Acute Myocardial Infan
(a)
1.1.3 ..... Pleasant ..... St ....
No.
Frederick B O'Regan
2 FULL NAME
(First Name) (Middle Name) (Last Name)
St.
(If nonresident, give city or town and State)
19
3 DATE OF
DEATH
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
-
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
1.12
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
OF TOWN
&
... 6.2
WINTHROP
JAN 151962 FIT
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.
ORM R-303
3 DATE OF DEATH Manner of Injury Nature of Injury 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 §§ 44-48. 50M- 3-61-930213 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of While at work ?
7
1
(County) WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE 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.
8
5 Irwin St. Winthrop S(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) No.
PHYSICIAN - IMPORTANT
2 FULL NAME
ALICE C. EAGAN
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married. widowed or divorced woman, give also maiden name.)
[ (Was deceased a
₹ U. S. War Veteran,
lif so specify WAR)
5 Irwin Street
St.
Winthrop, Massachusetts
(If nonresident, give city or town and State)
Length of stay: In place of death ........ .. years. .. months days. In place of residence.
.years ............ months ........
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
9 SEX 10 COLOR
11 CITIZEN
OF U.S.
YES
NO
12 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
12a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
13 DATE OF BIRTH
14
AGE/5 Years.
.... Months .......... .. Days
....
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, on
in
1 Social Security No.
18 BIRTHPLACE (City)
(State or country)
mass
19 NAME OF FATHER
Jahn wine Gowan
(unknown)
21 MAIDEN NAME OF MOTHER
(Unknown)
22 BIRTHPLACE OF MOTHE (State or country)
23 Informant Address)
Richart Rd Mechan
HEREBY CERTIFY that a satisfactory standard certificate of death filed with big BEFORE the burial of tranci ned:
agent ul body of Health or othery
Jan 15, 1962
(Official Designation)
(Date of Issue of Permit)
1.13.
A TRUE COPY ATTEST:
(Registrar)
PARENTS
(Signed) M. D.
(Address) 25 Shattuck St. Date 1/12/ 1962 Needham Cemetery Muchom 7
Place of Burial, or Cremation. (City or Town)
15
DATE OF BURIAL January 19
8 NAME OF FUNERAL DIRECTOR Jasephatalle ADDRESS 1305 Highland one needham more
1
PLACE OF DEATH
SUFFOLK
(a) Residence. No. (Usual place of abode) (Day) (Month) 5 Accident, suicide, or homicide (specify) Leonard Atkins , ... V. D (Print or Type Name) If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. public place ? (Specify type of place)
January
12,
1962
(Year)
4 I 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.)
HYPERTENSIVE
ARTERIOSCLEROTiC
CARDIOVASCULAR DISEASE
If under 24 hours Hours Minutes
15 Usual Occupation :
Registered Duvel work done during most of working life)
16 Industry Bu iness: Winthrop Hospital
Brockton
20 BIRTHPLACE OF FATHER ((y) (State or country)
6 Was disease or injury in any way related to occupation of deseased? If so, specify
(How did injury occur ?)
Received and filed JAN 15-1962 19
FEMALEWHITE
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TOP
OF
.1.12
V
6
25
HROP.
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 whont 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) Winthrop (City or Town) Mounts
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Convalescent Home
[(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)
No
(If deceased is a married, widowed or divorced woman, give also maiden name.)
83 horing. Rd
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death .. years .. 9 months 2.2
days. In place of residence ... Q ..... years.
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCELingle
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
91
Years.
Months.
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
At Home
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
Boston
16 BIRTHPLACE (City) (State or country) Mass
17 NAME OF
FATHER
Jeremiah Hurley
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
M. D. OF MOTHER Annie Barret
20 BIRTHPLACE OF MOTHER (City) (State or country) Lreland
21 Informant (Address) Charles Blais 83 Loring Road 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)
Thealth Check
(Official Designation)
(Date of Issue of Permit) 1/15/62
ISTRUCTIONS FOR CAL CERTIFICATE
In giving E OF DEATH o not enter ore than one use for each a), (b) and (c)
does not mean mode of dying, as heart failure, ia, etc. It means sease, or compli- which caused
ditions, if any, ch gave rise to e cause (a), ing the under- g cause last.
onditions contrib- to death but not to the terminal condition given
e :- Chapter 137, of 1954. requires cians to print or the cause or s of death on certificates, and er 48, Acts of requires Physi- to print or type under signature. C.
Notin
(Signed)
John F. Collins MD
(PRINT OR TYPE SIGNATURE)
(Address) 27 Benningte ST 14 Jan 1962
Date.
6
HolyCross ..
Place of Burial or Cremation
Malden Mass
DATE OF BURIAL
January 16
of Town) 19.62
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O' Maley
Winthrop Mass
ADDRESS
Received and filed JAN 15-1962 .. 19
(Registrar)
INTERVAL BETWEEN ONSET AND DEATH 5 yrs
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arterioscleruite Herat
(a)
Diecse
(b) Arteriosclerosis
cfrs
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis ?
Cancel Findingi
5 Was disease or injury in any way related to occupation of deceased? V If so, specify
PARENTS
3 DATE OF
J
January.
74
19.62
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
April 23
.57
to ..
January
19
That I attended deceased from
14
1962
I last saw heralive on
January 9, 1962
death is said to
have occurred on the date stated above, at
12.16 Pm.
St. winthrop
(If nonresident, give city or town and State)
To be filed for burial permit with Board of Health or its Agent.
Registered No.
No.
Hurley Annie Lucy Hurley Lucy C.
2 FULL NAME
RM R-301A 1
M-6-59-92 5686
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
iv. ">
SERVICE NUMBER
TONY
OF
1
6 . ...
RULES OF PRACTICE JAN 1.51962 PM
The fulfillment of the purpose of these laws calls for the observance of 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
Suffolk (County)
2-9-12
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.
10
Registered No.
§(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME Mary.R .... Kidder (First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
44 Maple St., Marblehead Mass. st.
(L'sual place of abode)
Length of stay: In place of death ... .. years. 68
months. .days. In place of residence 30 .. years. months. .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FEMALE
9 COLOR
WHITE
10 SINGLE
MARRIED
(write the word)
3 DATE OF
DEATH
January
17
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
Nor
10
That I attended deceased from
1967
I last saw heralive on
JAN.
17 1962, death is said to
have occurred on the date stated above, at
7:05Pm.
(or) WIFE of
ARTHUR C. KIDDER
(Husband's name in full)
II IF STILLBORN, enter that fact here.
12
AGES 7 Years.
4)
Months /2 Days
If under 24 hours
Hours.
.Minutes
13 Usual
Occupation :
SCHOOL TEACHER
(Kind of work done during most of working life)
14 Industry
or Business :
TOWN OF MARBLEHEAD
15 Social Security No.
16 BIRTHPLACE (City)
MARBLEHEAD
(State or country)
MASS
17 NAME OF
FATHER
CHARLES F. DOE
18 BIRTHPLACE OF
FATHER (City)
MARBLEHEAD
M. D.
(State or country)
MASS
19 MAIDEN NAME
OF MOTHER
ANNIE P. HARRIS
20 BIRTHPLACE OF
MOTHER (City)
MARBLEHEAD
(State or country)
MASS
21
Informant
MAS
JOSEPH SMETHFÜRST
(Address)
ANDOVER, MASS
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)
(Official Designation)
(Date of Issue of Permit) 1/19/2
ISTRUCTIONS FOR EICAL CERTIFICATE
In giving BE OF DEATH o not enter ore than one use for each £1), (b) and (c)
does not mean mode of dying, his heart failure, ha, etc. It means sease, or compli- which caused
clitions, if any, uh gave rise to be cause (a), king the under- cause last.
nditions contrib- w'o death but not to the terminal condition given a
te :- Chapter 137, of 1954. requires icians to print or the cause or 1:s of death on 1 certificates, and ter 48, Acts of 5 requires Physi- . to print or type under signature.
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