USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 33
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29 Pico Ave., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death filed with me BEFORE the burial or transit permit was lequed: R.K. Form
(Sighafure of Agent of Board of Health or other)
B12435
8-9-62
(Official Designation) (Date of Issue of Permit)
163
OUT - OF - TOWN .... DIVISION OF VITAL STATISTICS
SECRETARY OF THE COMMONWEALTH
(City or Town making this return)
I
Boston
(City or Town)
No. .......
New England Center Hospital
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, (if so specify WAR) No
(a) Residence. No ...
(Usual place of abode)
3 DATE OF
DEATH
August
8
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
July 6
19
62, to August 8
.62
I last saw h ...... alive on
August .8
62 ... , death is said to
have occurred on the date stated above, at
2: 30a.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATY.
1 MO.
Due To
(b)
GLOMERULONEPHRITIS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
DIABETES MELLITUS
Was autopsy performed ?
.Y.E.S.
What test confirmed diagnosis ?
RENAL BIOPSY
5 Was disease or injury in any way related to occupation of deceased ? NO If so, specify
(Signature)
Matthew E. Revine
M. D.
....
MATTHEWE. LEVINE
(Print or Type Name)
(Address) NEW ENGLAND Date 8/8 1962
4 MOS.
(Give maiden name of wife in full)
(a) RENAL FAILURE
The Commonwealth of Massachusetts KEVIN H. WHITE
A TRUE COPY ATTEST: Kurus it Mackie City Registrar
OCT -51962 AM
-
164
OUT . OF - TOWN
(City or Town making this return)
07993
Registered No.
[(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 .. ....
(a) Residence. No .....
174 Cottage Park Road
(Usual place of abode)
st.Winthrop ,Massachusetts
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months.
2
days. In place of residence.4.2years.
.. months.
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
August 12 1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That Wettended deceased from
August ..... 10 19 ..... 6.2 .. , to ...
August ..... 1.2
19.
.62 ..
W last saw himive on August ..... 12.
1962. death is said to
have occurred on the date stated above, at
4 :. 0.5a.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Pulmonary atelectasis
INTERVAL BETWEEN ONSET AND
(a)
Due To
(b)
........ Myasthemia gravis
2 Years
Occupation :
( Kind of work done during most working life)
14 Industry
or Business: Wholesale ..... Electrical
15 Social Security No ..
324-05-8358 ( Supplies
16 BIRTHPLACE (City)
Chelsea
(State or country)
Mass
17 NAME OF
FATHER '
Charles Woodbury Baker
18 BIRTHPLACE OF
FATHER (City)
Chelsea
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Annie Florence Cardy
20 BIRTHPLACE OF
MOTHER (City).
Chelsea
(State or country)
Mass
Woodlawn Cemetery Everett Mass 6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
August 16,1962
7 NAME OF
FUNERAL DIRECTOR
alfred To March
ADDRESS 174 Winthrop Street, Winthrop,
Received and filed AUG 1.6 1962 . 19 Charles 4. mackie
8 SEX
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
married
male
11 If married, widowed, or divorced
Winifred Knowles
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
hour
12
AGE7.8 .. Years ..
.2.
.Months.
13 .. Days
If under 24 hours
Hours.
Minutes
Due To (c) ....
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis ?
autopsy
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
(Signature)
M. D.
Charles L. Clay, M.D.
(Print or Type Name) (Address) Asalt .. Dir.,.Mass .. Gan.l .. Hasp ...... Dat A.ug ... 12 ..... 19.62.
PARENTS
21 Informant
Mrs ....... Irving ..... C ...... Baker
( Address) 174 Cottage Park Rd. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death andwith me BEFORE the burial or trash permit was issued:
(Signature of Agent of Board of Health or other)
12494
8/15/62.
(Date of Issue of Permit)
le for burlal permit Jard of Health 01 ta Agent. N: RUCTIONS FOR CI CERTIFICATE
NOR TYPE' SEDR CAUSES DIDEATH de sot enter a than one t: for each a (b) and (c)
s'oes not mean mie of dying, a heart failure, desc. It means is se, or compli- s which coused
dions, if any, c' gave rise to DI cause (@), in the under. ut cause last.
cfitions contrib- i deoth out mot do the terminal e Condition given C .
44 .
126
ul Directeft 's use only LICK Ink. CT 5 - 1982 62-932382
PLACE OF DEATH
SUFFOLK
..... (County)
-
BOSTON
(City or Town)
NO.MASSACHUSETTS GRAL .. HOSPITAL
2 FULL NAME
Irving ..
Cardý C. Baker
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PERSONAL AND STATISTICAL PARTICULARS
13 Usual
Retired salesman
(Registrar)|| (Official Designation)
ORM R-301
RUE COPY ATTEST: arles it Mackie Gay Registrar
OCT - 51962 AM
F R-301A 1
D
N RUCTIONS FOR IC. CERTIFICATE
giving S OF DEATH d not enter we than one ale for each (a (b) and (c)
isdoes not meon nde of dying, heart failure, ms etc. It means fisse, or compli- is which caused
mions, if any, gove rise to cause (a), the under- cause last.
C ditions contrib- death but not o the terminol se ondition given
te Chapter 137, o1954. requires iuns to print or e cause or es of death on rtificates, and 48, Acts of quires Physi- print or type e der signature. S
50-11-59-926662
PLACE OF DEATH
X Suffolk (County) Winthrop (City or Town)
16 -5-6°2
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.
165
Registered No.
[(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.)
310 Princeton St. St.
Fast Boston MASI
(If nonresident, give city or town and State)
months ..
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Septembre.
3.
Month)
(Day)
1962
(Year)
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIED
(write the word)
single
or DIVORCED
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
Years.
Months.
Days
2
If under 24 hours
Hours.
Minutes
none
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
**
15 Social Security No.
none
16 BIRTHPLACE (City)
(State or country)
Winthrop, Mass.
17 NAME OF
FATHER
Albert Vitello fr.
18 BIRTHPLACE OF
Revere
FATHER (City)
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Harriet Littlefield
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Maine
6 St. Tarcisius Cemetery Framingham, Mass.
Place of Burial or Cremation
Sept. 4.
19.62
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Vincent Kapino
ADDRESS 9 Chelsea St., Cast Boston, Mass
Received and filed SE7 4 1982 ... 19 ..
( Registrar)
PARENTS
Albert Vitello (father)
21
Informant
(Address)
310 Princeton St. East Boston Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: TPalph 6° stirianne
(Signature of Agent of Board of Health or other)
Health Officer
9/4/62
(Date of Issue of Permit)
(Official Designation)
V
.
I ritellas
2 FULL NAME
Baby girl
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death. ........... years. months.
That I attended deceased from
196V
Soft
1
١٧٠
to
I last saw he.y .. alive on
Sunt 3
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Prematurity. 34th warts.
(a)
Birth weight ()4 165. 21/4 0).
Due To (b)
Due To (c)
HYdr.
OTHER
SIGNIFICANT Mdrochhalus
Photocu Mella
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
M. D.
ATALL DERHAGOPIDAIN
(PRINT OR TYPE SIGNATURE)
(Addre
39 CARY AV. CHELSEA Date Sunt 3.
196V
4 I HEREBY
CERTIFY
5
It.3
19. .. V ...... , death is said to
have occurred on the date stated above, at : 40 A
.. m.
INTERVAL BETWEEN ONSET AND DEATH
2 dias
PERSONAL AND STATISTICAL PARTICULARS
2 days. In place of residence .. .......... years.
No. Winthrop Community Hospital
01
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
9
CAK
THROP.
RULES OF PRACTICE SEP -41962 PM
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.
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
WinthropConvales cent HOME 142 Pleasant St
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.
166.
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,
(if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
59 Pebble Ave
St
(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
3 DATE OF
September 11, 1962
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
AUG 5
1958
to VARTEMBER 11
19.62
I last saw h ?..... alive on
SEPTEMBER11, 1962, death is said to
have occurred on the date stated above, at
11:40Pm.
10a If married
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.7.9.
Years ...........
Months ...
Days
If under 24 hours
Hours .............
Minutes
13 Usual
Occupation :
Retired Salesman
(Kind of work done during most of working life)
14 Industry
or Business :
Drug Supplies
15 Social Security No. Needham.
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
Frederick Chapman
18 BIRTHPLACE OF
FATHER (City)
Canton
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Emma Crowell
20 BIRTHPLACE OF
MOTHER (City)
Needham
(State or country)
Mass
21 Sadie G. Chapman
Informant
(Address)
59 Pebble Ave. 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 of other) Galthe Office
9/13/62
(Date of Issue of Permit)
7 (Official Designation)
6-028145
AR-301A 1
STUCTIONS OR ULCERTIFICATE
.niving SIF DEATH
it enter re han one s.for each ),b) and (c)
e's not mean @ of dying, s eart failure, , tc. It means 6, or compli- hich caused
itis, if any, i ive rise to ause (a), gihe under- ause last.
mions contrib- o eath but not Iithe terminal adition given
C.
te Chapter 137, 01954. requires runs to print or le cause or sof death on rtificates, and tı 48, Acts of quires Physi- print or type : der signature.
6 Canton Cemetery Canton ....... Mas.s Place of Burial or Cremation
(City or Town)
DATE OF BURIAL September 14
1962
7 NAME OF FUNERAL DIRECTOR Arthur J. O'Maley
ADDRESS
Winthrop, Mass
Received and
9/13/1962
( Registrar )
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDried
sadiogedG . Wright
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) ACUTE MYOCARDIAL INSUFFTENGO
INTERVAL BETWEEN ONSET AND DEATH 2DAYS
Due To
INSufficient
(b) ARTERIOSCLEROTIC HEART JUNEASE 4YRS
Due To
(c)
ARTERIOSCLEROSIS
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
No
What test confirmed diagnosis?
NO
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed) Dorothy Cheney appleton M. D DOROTHY Cheney APPLETON M.D (PRINT OR TYPE SIGNATURE)
(Address) 197Woodside que Date SEPT 12 1962
94RS
PARENTS
CENSE PET
No.
2 FULL NAME Chester B. Chapman (First Name) (Middle Name) (Last Name)
(Usual place of abode)
20
35
(write the word)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE SEP 1 31962 PM
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.
× 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.
1.62
(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
Maude
Dow
Cole
(If deceased is a married, widowed or divorced woman, give also maiden name.)
49 Bates Ave
St.
Winthrop Mass
(If nonresident, give city or town and State)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death.
............ years.
months.
7
.days. In place of residence
years.
months.
.days.
2
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
Sept
DEATH
(Month)
(Day)
1962 (Year)
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED Widow
or DIVORCED
4 I HEREBY CERTIFY,
Nov
1959, to SEDX
That I attended deceased from
11
1962
I last saw h.Y.alive on
Sept
111
1962
., death is said to
have occurred on the date stated above, at 2. 40 Pm.
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFBanjamin& Cole
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
77
11
1
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
At home
15 Social Security No.
Albany
16 BIRTHPLACE (City)
(State or country)
Vermont
17 NAME OF
FATHER
James Dow
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Vermont
19 MAIDEN NAME
OF MOTHER
Ellen Hayden
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Veränt
21 Margaret Brogan
Informant (Address)
49 Bates Ave. winthrop, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Halfile terranno (Signature of Agent of Board of Health of other)
Healthe officer Official Designationy
(Date of Issue of Permit)/
V
I:RUCTIONS FOR CERTIFICATE
giving OF DEATH
not enter than one for each (b) and (c)
oes not mean e of dying, heart failure, Betc. It means sse, or compli- which caused
ons, if any, gave rise to cause (a), the under- cause last.
Due To Atrial Fibrillation
(c)
OTHER SIGNIFICANT CONDITIONS
W'as autopsy performed?
200
What test confirmed diagnosis? Clinical
5 Was disease or injury in any way related to occupation of deceased? NO. If so, specify
(Signed)
CHARLES
LIBERMAN
(PRINT OR TYPE SIGNATURE)
(Address) WINTHROP MASS Date.
9/11/ 1962
6
Winthrop
Winthrop
Place of Burial or Cremation
DATE OF BURIAL
Sept.
13
19 62
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS
Winthrop, Mass
Received and filed
SEP 12 1962
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cerebral Embolus
INTERVAL BETWEEN ONSET AND DEATH
/ week
Rheumatic Heart Disease
(b)
40yrs
5yrs.
PARENTS
011-59-926662
HI R-301A 1
Ditions contrib- t death but not Ib the terminal condition given . C.
e Chapter 137. 954. requires ens to print or e cause or sof death on ctificates, and te 48, Acts of quires Physi- t print or type ler signature.
C. Titre Muchy, M. D.
(City or Town)
Registered No.
No .. Winthrop Community Hospital
PHYSICIAN - IMPORTANT [(W'as deceased a U. S. War Veteran, (if so specify WAR)
9/12/62
11
AGE
Years.
Months
Days
048-18-8866
-
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
1
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
SEP .1:21962.TM
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.
BI R-301 1
STUCTIONS :OR AICERTIFICATE
Ingiving E)F DEATH
it enter n:han one s for each ), b) and (c)
es not meon o of dying, s yeart foilure, 1, tc. It meons ett, or compli- which caused
tas, if any, ive rise to ouse (0), g'he under- ouse lost.
tions contrib- coth but not t the terminal adition given
. ,
Chapter 137, c 1954 requires inns to print or he cause or E of death on rtificates, and t 48, Acts of quires Physi- print or type der signature.
St. Joseph's
Purlington, Vermont
6
Place of Burial or Cremation
Sept
19
(City or Town)
62
DATE OF BURIAL 19
7 NAME OF
FUNERAL DIRECTOR
Frederick J. Magrath
ADDRES25 Chelsea St .E-Foston
Received and filed
SEP 18 1962
(Registrar)
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
lla If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of Alfred H. Queenan
(Husband's name in full)
12 DATE OF BIRTH
13
69
Years.
Months ..........
.. Days
If under 24 hours
.Hours ...
.Minutes
14 Usual
Occupation :
housework Houser
(Kind of work done during most of working life)
15 Industry
or Business:
own home
16 Social Security No.
Burlington
17 BIRTHPLACE (City)
(State or country)
Vermont
18 NAME OF
FATHER
John Purns
19 BIRTHPLACE OF
FATHER (City)
Burlington
(State or country)
Vermont
20 MAIDEN NAME
OF MOTHER
Mary A, Purcell
21 BIRTHPLACE OF Virgennes MOTHER (City) (State or country) Vermont
22 Informant Alfred H. Queenan (Address) 47 Loring Rd. 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) Health Slices
Il (Official Designation)
(Date of Issue of Permit)-
9 18/62
-930213
PLACE OF DEATH
Suffolk
(County) Winthrop
CINSI PETIT
The Commonwealth of Massachusetts KEVIN H. WHITE 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.
168
[(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,
lif so specify WAR)
no
(Last Name)
Lf deceased is a married, widowed or divorced woman, give also maiden name.)
47 Loring Rd.
Winthrop
St
(1f nonresident, give city or town and State)
Length of stay: In place of death. .years .. months. .days. In place of residence. .years ...
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
Sept.
DEATH
(Month)
(Day)
(Year)
4 I HEREBY
NOV.
19
CERTIFY,
52 to Sept. 15
That_1_attended deceased from
196.2
I last saw helalive on
Sept ........ 15
19.62., death is said to
have occurred on the date stated above, at 11.150 m.
INTERVAL BETWEEN ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cancer, Peritoneal
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
none
no
Was autopsy performed?
What test confirmed diagnosis?
clinical
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
Charles Liberman
no
M. D. Charles Liberman Winthrop,or Malgyme) 9/15 62
(Address)
Date
19
PARENTS
(City or Town)
Winthrop Community Hospital
No.
2 FULL NAME
Anna B. Queenan
(First Name)
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