USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 24
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No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board. agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied. in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six. that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate. shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies of persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. . - General Laws, Chap. 38, Sec. 6 . as amended.by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall bury ;a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the check of the toup where the body is to be buried or the funeral is to be held, or from a person-appointed to have the care of the cemetery or burial ground in which the interment-'s made.
Chap. 114, Sec. 46, G. L., (Tercentenary , Edition). FLERE RULES OF PRACTICE
The fulfillment of the purpose of
hase laws calls for the observance of the follow- ing rules of practice: (1) Attending physicians wi Tc auch deaths ofly as those of persons to whom they have given bedsides ng afast illness from disease unrelated to any form of injury. IN No such deaths only as those of
(2) Board of Health physiciany persons who, though disabled by
ted.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 esfigate and certify to all deaths supposably due to injury. These include
directly or indirectly by traumatism (including resulting septleenAr 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 occupation, 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 import- ant, 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. Children 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.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town) 20 Dix
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.
120
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
(First Name)
(Middle Name)
(If deceased is a married. widowed or divorced woman, give also maiden name.)
(Last Name)
[if so specify WAR)
165 Woodside Ave.
St.
(If nonresident, give city or town and State)
months
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED Widow
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Charles C Smith
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
81
AGE
Years.
4
Months.
23
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.
Lowell
16 BIRTHPLACE (City)
(State or country)
Lass.
17 NAME OF
FATHER
Charles L Adams
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Maine
19 MAIDEN NAME
OF MOTHER
Unable to obtain
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
l'aine
21 Pauline Cook
(Address)
Informant
....
20 dix Street, winthrop, Lass
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)
4/2/10
(Official Designation)
(Date of Issue of Permit)
5 UCTIONS :OR CERTIFICATE
giving HOF DEATH ot enter than one us for each (b) and (c)
Des not mean of dying, sheart failure, Retc. It means te, or compli- which caused
is, if any, have rise to ecause (a), the under- cause last.
"tions contrib- death but not the terminal ndition given
.C.
- Chapter 137, 1954, requires ians to print or he cause or of death on ertificates, and r 48, Acts of equires Physi- print or type ender signature.
6
Woodlawn Crematory
Everett
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
July
2
19
62
7 NAME OF
FUNERAL
DIRECTOR
Howard S Reynolds
Winthrop, Mass
ADDRESS
Received and filed JUL & 1962
19
(Registrar)
PARENTS
M. D
Arthur C. Murray
(PRINT OR TYPE SIGNAT
Winthrop Board of Herbate 30
LASURE) June 1962
(Address)
Was autopsy performed? no What test confirmed diagnosis? post-mortem judgement
5 Was disease or injury in any way related to occupation of deceased? no If so, specify
(Signed)
arthur C. Murray
/ WK
Due To
(c) Arteriosclerotic Heart Disease
OTHER
SIGNIFICANT
CONDITIONS
none
INTERVAL
BETWEEN
ONSET AND
DEATH
(a)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Natural Causes
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
19
19
I last saw h.e.f.alive on ·19. death is said to
have occurred on the date stated above, at
5:15 P.m.
3 DATE OF
DEATH
June
29
Ethel L (Adams) Smith
[ (Was deceased a U. S. War Veteran,
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death
years
.. months.
.. 7 ... days.
In place of residence.
5.4 ... years
No.
0-928145
R-301A 1
Due To
(b) Presumably Coronary Occlusion
years
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
1
K
6
HROP
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for following rules of practice : NUL 2 and 1962 AM
(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.
RM R-302
feat ( les of tei WRITE PLAINLY, WITH UNFADING DUALA INA VK USE ASFAUVEU ULALA LLANTA Ve after the cle of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) hould be transmitted on Form R-302 to th clerk of the city or town in which the deceased of deathy wh. h occurred in your city or town in case the deceased resided 'n another city or town THIS IS A PERMANENT RECORD
..... to be completo & accurate.
V. . #612 Ra - 1956
NON RESICENT
CERTIFICATE OF DEATH FLORIDA
STATE FILE
REGISTRAR'S NO.
1. PLACE OF DEATH 0. COUNTY
CODE NO.
18.027
2. USUAL RESIDENCE ( Where deceased lived. If institution: Residence before admission) a. STATE b. COUNTY Massachusetts
8. CITY. TOWN. OR LOCATION
c. CITY. TOWN, OR LOCATION
Punta Gorda., Fla ...
c. IS PLACE OF DEATH
INSIDE CITY LIMITS?
YES K
NO
Winthrop
c. IS RESIDENCE INSIDE CITY LIMITS! YES DO NO
d. NAME OF
HOSPITAL OR
INSTITUTION 200 Kenyon Ave. P. C. 13 Mos
€. LENGTH OF
STAY IN 18
d. STREET ADDRESS
RR-20
ON A FARMT YES O NO IX
Firat
Middle
Last
Month
Dey
Year
3. NAME OF DECEASED (Type or print) JOHN
A.
MOLLOY
DATE
OF
DEATH
March
30, 1962
5. SEX
-
Write pleinly with per- einent blook ink
typewriter
Phialip Molloy
15. WAS DECEASED EVER IN U. S. ARMED FORCES? (Yes. no, or unknown) Yes
16 SOCIAL SECURITY NO. 17. INFORMANT'S SIGNATURE 023-14-6498
Address 131 Bartlett Rd. Winthrop Maps
18. CAUSE OF DEATH [Enter only one cause per fine for (a), (b), and (c).)
PART I. DEATH WAS CAUSED BY:
IMMEDIATE CAUSE (0)
Coronary occlusion
INTERVAL BETWEEN ONSET AND DEATH immediate
Conditions, if any, which gave ring to above cause (0), stating the under- iying cause last.
DUE TO (b)
DUE TO (c)
PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART I(a)
19. WAS AUTOPSY
NO
PERFORMED?
YES
20g. (Probably) ACCIDENT
SUICIDE
HOMICIDE
.
20c. TIME OF
INJURY
Hour 0. 1. p. m.
Month, Day, Year
20d. INJURY OCCURRED
20c. PLACE OF INJURY (c. g., in or ahout home, farm, factory, street, office bldg., etc.)
20/. CITY. TOWN. OR LOCATION COUNTY
STATE
WHILE AT WORK
NOT WHILE AT WORK
21. I attended the deceased from. Death occurred at 10 A .M. m on the date stated above; and to the best of my knowledge, from the causes stated.
22g. SIGNATURE
236. DATE
23d. LOCATION (City, town, or county)
(State)
Removal
April 1,'62
24. FUNERAL DIRECTOR'S SIGNATURE
ADDRESS
25. DATE RECD. BY LOCAL REG.
Edward R. Pongu Punta
Gorda, Fla.
APR 2 1962
26. REGISTRAR'S SIGNATURE
Edith Jones, Deputy
1
U.S.A
East Boston, Mass. 14. MOTHER'S MAIDEN NAME Rachel B. Bradley
12. CITIZEN OF WHAT COUNTRY
10g. USUAL OCCUPATION (Gise kind of work done during most of working life, even if retired) Linotype Operator 13. FATHER'S NAME
7.
MARRIED
NEVER MARRIED
8. DATE OF BIRTH
9. AGE (In yeare
ian birthday)
65
IF UNDER 1 YEAR IF UNDER 24 HRS. Monthe Mis.
Male
6. COLOR OR RACE
White
WIDOWED
DIVORCED
Sept. 4,1896
100. KIND OF BUSINESS OR INDUSTRY |11. BIRTHPLACE (State or foreign country)
Printing
Funeral diector sunt file the cer- tificate with the
registrar within 72 hours af- tor death or before utling any dispoo1- tion of body . 4/201
MEDICAL CERTIFICATION
NOSI
at h re ided
PLACE OF DEATH
CHARLOTTE
(County) Punta Gorda Florida
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or Town making this return)
131
Registered No.
[ {If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
No.
JOHN A. MOLLOY
( If deceased is a married, widowed or divorced woman, give also malder name.)
( Was deceased a U. S. War Veteran, (if so specify WAR, ...
W.W.I.
62-010547
BIRTH NO.
1 gel rec- 'd when properly oleouted
Charlotte
৳ pleced 1 per- u nent r 10.
1
200 Kenyon Avenue, P. C.
2 FULL NAME.
23a. BURIAL, CREMATION. REMOVAL (Specify)
(Degree or tiie) M.D.
and fast saw her alive on
--- 5-30-62
hím
22b. ADDRESS 22c. DATE SIGNED III W. Olympia cre Punta Sonda Pin 4-2-62
23c. NAME OF CEMETERY OR CREMATORY St. Joseph Cemetery
East Boston. Mags
Florence Wollen
(If yes, give war or dales of service)
W.W.I
0
200. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Part I or Part II of item 18.)
131 Bartlett Road
(If not in hospital, gisc street address)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
PLACE OF DEATH
SUFFOLK
(County)
I
BOSTON
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
122 ....
(City or Town making this return)
Registered No.
86092
[(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
66 Shore Drive
(Usual place of abode)
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
8 SEX
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN divorced
! HEREBY CERTIFY , That weattended deceased from
19 ..... 62
May ...... 16.
1962 ....... , to ..... June
15
we ] last saw hpalive on .
June
15
3.1:04am
19.
.. jegth is said to
have occurred on the date stated above, a
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .MyocardialInfarction ..
INTERVAL
(or) WIFE of
12
BETWEEN
ONSET AND
DEATH
UnkWk
3 AGE.
81
l'ears
.Months .....
.. Days
If under 24 hours
Hours ..
.Minutes
UnkYrs 13 L'sual
Button Maker (retired)
Occupation :
(Kind of work done during most working ilfe)
14 Industry
or Business:
Factory
15 Social Security No ......
014-20-4767
16 BIRTHPLACE (City)
(State or country)
Russia
Was autopsy performed ?
yes
What test confirined diagnosis ?
autopsy
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
(Signature)
chillar
M. D.
Charles L. Clay, M. D.
(Print or Type Name) (Address)Ass's .. Dir ... Masa ... Gan'] .. Hosp ........ Date ..
June 15 62
6 .David ... Vicur .Choulim(Lebanon)W.Roxbury
Place of Ilurial or Cremation
(City or Town)
DATE OF BURIAL
June 17, 1962
7 NAME OF
FUNERAL DIRECTOR
Benjamin F. Solomon
420 Harvard Street, Brookline.
ADDRESS
JUN 20 1962
Received and filed
Charles H. Mackie
.......
19
Mrs. Lillian(Sidney) Balkan
21 Informant
( Address)
20 Taylor Street, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was hled with me BEFORE the burial or transit permit was issued:
A 09258
(Signature of Agent of Bothof Health or other) June 16 1962
(Date of Issue of Permit)
XX
-
female
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Frank
Lottman
(Husband's name in full)
Due To
(b) .........
Coronary Artery Occlusion
Due To (c)
OTHER
SIGNIFICANT
....
Pulmonary ........ mb.o.l.i.sm.
Unk Days
....
CONDITIONS
June
15
1962
(Month)
(Day)
(Year)
2 FULL NAME
(If deceased
a married, widowed or divorced woman, give also maiden name.)
(a) Residence. N
NOMASSACHUSETTS .. GENERAL .. HOSPITAL
E . Bessie Lottmanji
6 1 for burial permit hoard of Health its Agent. I TRUCTIONS FOR OIL CERTIFICATE
IT OR TYPE JS: OR CAUSES ( DEATH not enter a'e than one ci se for each (. (b) and (c)
lut does not mean ode of dying, heart foilure. ens, etc. It means cease, or compli- which caused
mitions, if any, las gove rise to because (a), as the under. cause last.
Unditions contrib- to death but not so the terminal condition given C. -20.1 81 170 9 1962 al Director No use only ACK Ink.
1-62-932382
A TRUE COPY ATTEST:
PARENTS
17 NAME OF
FATHER
Jacob Bortnick
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Anna Cohen
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Russia
-
(Registrar) | (Official Designation)
(write the word)
3 DATE OF
DEATH
- OF - TOWN!
FORM R-301
'A' TRUE COPY ATTEST; Charles it Mackie
City Registrar
RECEIVED
OF
TOWĄ
12
OFFI
MI.1
5
CLERK
5 5
HRS
AUG =91962 AM
IM R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
(Usual place of abode)
3 DATE OF
DEATH
June 24, 1962
(Month)
(Day)
(c) .
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
no
What test confirmed diagnosis Laboratory
(Address).no address
6
Winthrop
Winthrop
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
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
Due To
ånd metastases to liver
25M-8-56-918227
PLACE OF DEATH
Essex
(County)
Saugus (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Saugus.
(City or Town making this return)
Registered No.
130
"(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
2 FULL NAME
Marie G McMath (Mann)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ....
68 Crystal Cove Ave Winthrop Mass
(Was deceased a
U. S. War Veteran,
if so specify WAR)
no
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years.
months.
1.days. In place of residence .___ years.
months
.. days.
MEDICAL CERTIFICATE OF DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Pneumonia
INTERVAL BETWEEN ONSET AND DEATH
Due To
Carcinoma of gall bladder 6 mo
(1))
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
Charles Costas M D
M. D.
Mo-date 19
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ... June 27m 1962
7 NAME OF
FUNERAL DIRECTOR Maurice W Kirby
ADDRESS. Winthrop Mass
Received and filed. JUL 161952 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWED
or DIVORCED
Widowe
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
John A McMath
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.
.7.Gears.
Months.
Days
If under 24 hours
Hours ......
Minutes
13 Usual
Occupation : Clerk
(Kind of work done during most of working life)
14 Industry
or Business: State Ins Dept.
15 Social Security No ....
none
16 BIRTHPLACE (City) Boston
(State or country)
Mass
17 NAME OF
FATHER
Joseph E Mann
18 BIRTHPLACE OF
FATHER (City)
Unknown
(State or country)
19 MAIDEN NAME
OF MOTHER
Alice McDonald
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Unknown
21 Informant. (Address) 2 Robent MOMbody
A TRUE COPY
ATTEST:
DATE FILED
(Registrar of City or Town where death occurred)
6-27-62
19
V.B.
.
(Year)
4 | HEREBY CERTIFY,
That I attended deceased from
6-6-
196.2 ... ,
to.
6-24-
19.62
I last saw h.elalive on
.June ... 24
1962., death is said to
have occurred on the date stated above, at
3 A.
.m.
PARENTS
No. Saugus .... General ..... Hospital
ORM R-301
ig for burial permit ard of Health Is Ageni N RUCTIONS FOR CERTIFICATE
OR TYPE SIOR CAUSES DEATH dinot enter e than one me for each 8 (b) and (c)
sloes mot mean ste of dying, u heart failure. w etc. Is means inse, or compli- s which caused
nions, if any, e gave rise to cause (a). the under- if cause last.
Cititions contrib. O death but not do the terminal e ondition given
720 135
1 9 1082
852-932382
PLACE OF DEATH
X OUT - OF - TOWN SUFFOLK : (County) 1 Boston (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
(City or Town making this return)
. CERTIFICATE OF DEATH
Registered No.
((If death occurred in a hospital or institution, Boston Luna-in HOSPITALS.( Rive its NAME instead of street and number) No.
BABY BOU De Viio 2 FULL NAME.
(li deceased is a/married. wid ved or divorced womad, give also maiden name.)
21 Wadsworth Ave
.. St
(If nonresident, give city or town and State)
Length of stay : In place of death.year ......... months. day. In place of residence. ........ year ......
PERSONAL AND STATISTICAL PARTICULARS
8 SEX MALE
9 COLOR
unite
10 SINGLE
MARRIED
WIDOWED
DIVORCED
( write the word)
Sing ::
11 If married. widowed, or divorced HUSBAND of (or) WIFE of ..
(Give maiden name of wife in full)
(Husband's name in full)
12
AGF ..
Years .
Month.
1
Days
If under 24 hour-
($ Hours /SMinutes
13 L'sual
Occupation .
( kind of work done during most working life)
14 Indus !* / or Business
15 Social Security No
16 BIRTIIPLACE (City) (State or country 1
Dustin NASS
PARENTS
17 NAME OF
FATIIER
GERALd A. DEirio
1& BIRTHPLACE OF
FATIIER (City).
(State of country )
Chicago.
LiniNois
19 MAIDEN NAME
OF MOTHER
CAROL STAVRENES
20 BIRTHPLACE OF
MOTHER (City ) ....
(State or country)
Winthrop
MASS
- Boston Lying-in Hospital 221 Longwood Ave, Poster.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed 'with me BEFORE the burial. or transit permit was issued: 1 1100
(Signature of Agent of Board of Health of other)
U
( Registrar) | (Officlal Designation)
(Date of Issue of Permit)
A TRUE COPY ATTEST:
. That I attended deceased from
4 I HEREBY CERTIFY
6-24, 1) 62
.. to.
JUNE
62
I last saw himnhve on
JUNE - 26,
.. "6 2 death is said to
have occurred on the date stated above, at 1 2:30 4-1.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Pulmonary Hemorrhage
Due To
(b)
Immaturity
(c)
OTHER SIGNIFICANT CONDITIONS
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