USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 41
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19
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Cambridge
(City or Town making this return)
160205
Registered No.
(Was deceased a
U. S. War Veteran,
no
(if so specify WAR Winthrop, Mass.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
Ilov. 12. 1962
(Day)
(Year)
4 I HEREBY CERTIFY
Oct. 3,
That I attended deceased
from
62
I last saw
Oralive on
Nov.
19
62
to.
NOV.
12
12
19
19. OCdeath is said to
have occurred on the date stated above, at
7:20an.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Carcinoma Right Breast
(a)
with Metastases to Lungs Due To (b)
INTERVAL BETWEEN ONSET AND DEATH 3yrs .
OTHER
General Arteriosclerosis
Was autopsy performed?
no
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
Edward T. Downey
M. D.
no
1
C.
2 FULL NAME. (a) Residence. No .. DEATH (Month) Due To (c) SIGNIFICANT CONDITIONS Boston 6 DATE OF BURIAL 7 NAME OF FUNERAL DIRECTOR 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 What test confirmed diagnosis ?
(Usual place of abode)
If under 24 hours
Hours. ...
.Minutes
Own Home
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT SERVICE NUMBER
RECEIVED
AF TO:
6
THROP
DEC -61962 AM
PLACE OF DEATH
Suffolk (County)
inthron (City or Town)
No. 57 Ocean View 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.
205
Registered No.
S(If death occurred in a hospital or institution, St. } give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
Mary Elizabeth Foy
(First Name)
( Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
57 Ocean View Street
St.
(lf nonresident, give city or town and State)
Length of stay: In place of death.
.. years.
months.
days. In place of residence ... 3. () ... years ........
.. months.
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
November 14, 1962
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
19
19
I last saw h ........ alive on
19 ............ , death is said to
have occurred on the date stated above, at
9:30 A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Natural Causes
INTERVAL BETWEEN ONSET AND DEATH
Due To
· Presumably Coronary Occlusion
(b)
Due To
(c)
Hypertensive Heart Disease
OTHER
SIGNIFICA Cirrhosis of Liver
CONDITIONS
5 yrs
Was autopsy performed?
What test confirmed diagnosis?
no clinical
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
arthur C. Murray
(Signed)
Arthur C. Murray
(PRINT OR TYPE SIGNATURE) Winthrop Board of lowy 15 Nov 1962
6 Wirthroo Cemetery
Winthrop
Place of Burial or Cremation (City or Town)
DATE OF BURIAL November 17 52
7 NAME OF
FUNERAL DIRECTOR
Arthur J. Offalev
ADDRESS Winthrop Mass.
Received and filed
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
white
10 SINGLE
(write the word)
MARRIED ".
WIDOWED!arried
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Robert W. Foy
maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
If under 24 hours
12
AGE51
Years
Months.
.Days
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.
16 BIRTHPLACE (City)
(State or country)
dass
17 NAME OF
FATHER
Roberts
18 BIRTHPLACE OF
Cannot be learned
FATHER (City) (State or country)
19 MAIDEN NAME
OF MOTHER
Cannot be learned
20 BIRTHPLACE OF MOTHER (City) (State or country)
Cannot be learned
21 Robert W .. 1', Foy
Informant
(Address) 57 (cear. V LAW St., 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 officer 11/16/62
(Official Designation)
(Date of Issue of Permit)
0-928145
R-301A 1
STJCTIONS OR AICERTIFICATE
Irgiving EOF DEATH bt enter nhan one s for each ), b) and (c)
es not mean 0 of dying, s Heart failure, 3,ttc. It means e2, or compli- which caused
ins, if any, have rise to cause (a), u the under- cause last.
ntions contrib- cleath but not the terminal ndition given
t- Chapter 137, 1954, requires ans to print or he cause or of death on ertificates, and r 48, Acts of equires Physi- to print or type ender signature.
PARENTS
Charlestown
no
M. D
[ ( Was deceased a U. S. War Veteran,
(if so specify WAR)
(a) Residence. No.
(Usual place of abode)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
NOV 1 61962 CM
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.
X PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
No.
27 Marshall Street
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.
[(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Annie J. Barry
(Murphy)
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
27 Marshall Street, Winthrop
(Usual place of abode)
Length of stay:
In place of death.
20
.years
months.
.days. In place of residence.2.Q ...
.years.
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
4 I HEREBY CERTIFY,
-
155, to.
15
Nov
That I attended deceased from
62
I last saw heralive on 14 Nov
62 death is said to
have occurred on the date stated above, at
-P.m.
INTERVAL BETWEEN ONSET AND DEATH
Due To
(b)
Cerebral Arteriosclerosis
Due To
(c)
Generalized Arteriosclerosis
OTHER
SIGNIFICANT
CONDITIONS
home
15 yrs
15 Industry
or Business :
At home
16 Social Security No.
None
East Boston
17 BIRTHPLACE (City)
(State or country)
Mass,
18 NAME OF
FATHER
Patrick Murphy
19 BIRTHPLACE OF
FATHER (City)
St. Johna
(State or country)
New Brunswick
20 MAIDEN NAME
OF MOTHER
Julia Desmond
21 BIRTHPLACE OF
Quincy
MOTHER (City)
(State or country)
Mass.
22 Joseph H. Barry-hus,
Informant
(Address)
27 Marshall St, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Malflic Serca
(Signature of Agent of Board of Health er other)
(Official Designation)
(Date of Issue of Permit)
TX
STJCTIONS OR AICERTIFICATE Irgiving E)F DEATH at enter rcthan one 18 for each ), b) and (c)
es not mean 10: of dying, s heart failure, a,tc. It means see, or compli- Which caused
iins, if any, have rise to ecause (a), nithe under- ause last.
ntions contrib- oleath but not the terminal ndition given
1 :- Chapter 137, 1954 requires Blans to print or the cause or e of death on Certificates, and pr 48, Acts of ,requires Physi- to print or type tender signature. 1.G.
61-930213
A TRUE COPY ATTEST:
PARENTS
Holy Cross Cemetery,
Malden
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL November 17th 19
62
7 NAME OF
DIRECT Richard C. Kirby, Inc ADDRESS91Bennington St., E.Boston
Received and filed NOV 16 152 19
(Registrar)
lla If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Joseph H. Barry
(or) WIFE of
(Husband's name in full)
12 DATE OF BIRTH
Aug. 16,1884
13
AGE ...
78 Years.
.2 ... Month
.2.9 .... Days
If under 24 hours
Hours.
.Minutes
14 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
Was autopsy performed?
What test confirmed diagnosis?
clinical
5 Was disease or injury in any way related to occupation of deceased? no If so, specify/ ...
(Signedy Arthur C. Murrayk. D.
Arthur C.
Murray
(Address)
(Print or Type Name) Winthrop Man Dat
16 Nov 1962
6
RI R-301 1
Registered No.
237
[(Was deceased a
U. S. War Veteran,
{if so specify WAR)
No
St
(If nonresident, give city or town and State)
3 DATE OF
DEATH
November 15
(Month)
(Day)
1962
(Year)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cerebral
Hemorrhage
10 yrs
11/12/64
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
1
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 OV 1 61962 FM
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 froin 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.
DRM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER KIBBUN -
MADEIN BECERVED FOR BINDING THIS IS A PERMANENT RECORD
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
PLACE OF DEATH
worcester
(County)
I
RUTLAND
(City or Town)
Veterans Administration Hospital
{(If death occurred in a hospital or institution, .St. ¿ give its NAME instead of street and number)
John Stewart Ryan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
23 Belcher
(a) Residence. No.
(Usual place of abode)
5
30
31
(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
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED Married
DIVORCED
UNKNOWN
(write the word)
DEATH
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY
19
to ..
19
Tlast saw
10:20
death is said to
have occurred on the date stated above, at
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE skin vertebrae, scapula, fivěr (a
peritoneal tissues, diaphragh bee to and mediastinum.
(b)
Postoperative
Carcinoma of the bladder Terminal .... Bronchial neumonia
1 yı
Days
14 Industry
or Business:
022-05-3913
15 Social Security No.
Orient
16 BIRTHPLACE (Cilyong ..... Island,N.Y. (State or country)
Was autopsy performed?
"Physical,x-ray & lab
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
R.L. Schulz, Inthologist
(Signed)
M. D.
VAH Rutland Hts., Masq. Nov.15 ,62
Winthrop Cemetery, Winthrop, Mass 6
Place of Burial or Cremation November '1'7" 62
19
7 NAME OF
Richard C. Kirby Ince
FUNERAL DIRECTOR
ADDRESS
917 Bennington St., E.Boston
Received and filed DEC - 1962 19
ATTEST:
(Registrar of City or Town where death occurtedy
1.0V.15,1962
DATE FILED
.. 19.
(Registrar of City or Town where deceased resided)
PARENTS
17 NAME OF
FATHER
Maurice John Ryan
18 BIRTHPLACE OF
FATHER (City)
(State or country)
County Cork
Ireland
19 MAIDEN NAME
OF MOTHER
Mary Ellen Gibbs
Tipperay ,
20 BIRTHPLACE OF MOTHER (City). (State or country)
Ireland
VA Hospital Records
21 Informant
(Address)
Rutland Heights, Nass.
A TRUE COPY Luida G. Hanff
No.
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
RUTLAND
(City or Town making this return)
Registered No.
(Was deceased a
U. S. War Veteran,
(if so specify WAR
Winthrop, Mass. St
11 If married, widowed, or anyd Jane Gagnon HUSBAND of
(or) WIFE of.
(Husband's name in full)
AGE
Years.
Months.
Dayz
If under 24 hours
Hours.
Minutes
Air Line Purchaser
13 Usual
Occupation :
(Kind of work done during most working life)
NOT THEABU
Lines
Due
(c)
OTHER SIGNIFICANT CONDITIONS
Tuberculosis, inactive
Yes
1 yr
INTERVAL
BETWEEN
ONSET AND
DEATH
12 69
10
21
(Give maiden name of wife in full)
3 DATE OF
November
15,
1962
.Novemberd festased 612"
50M - 10-61-931673
DATE OF BURIAL
2 FULL NAME.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
7/26/17
DATE OF DISCHARGE
8/16/19
RANK, RATING
Chief Yeoman"S/c
ORGANIZATION AND OUTFIT
Havy
SERVICE NUMBER
17475.90
OF TO:
11
1
Chik
DEC - 41962 FM
PLACE OF DEATH
X SUFFOLK (County) WINTHROP. (City or Town)
FINSE PETTO
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.
209
§(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)
2 FULL NAME.
DANIAL
FOLEY
(If deceased is a married, widowed or divorced woman, give also maiden name.)
97 LOWELL Rd.
........ St.
(If nonresident, give city or town and State)
Length of stay: In place of death ...
50 years.
.... months ..........
days. In place of residence 50 years.
months .............. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
(write the word)
10 SINGLE
MARRIED
WIDOWED
or DIVORCED MARRIED
VERKAMPEN
10a If married, widowed, or divorced
HUSBAND of ELIZABETH
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGED 4 Years
Months.
.Days
If under 24 hours Hours .. .Minutes
13 Usual
SCHOOL TEACHER(M.(.)
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
BOSTON PUBLIC SCHOOLS
15 Social Security No. 025-24-0452
BOSTON
16 BIRTHPLACE (City)
(State or country)
MASS
17 NAME OF
FATHER
PATRICK FOLEY
18 BIRTHPLACE OF
IRELAND
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
BRIDGET O'CONNOR
20 BIRTHPLACE OF
BOSTON
(PRINT OR TYPE SIGNATURE)
Winthrop Mass Date 19 Nov
1962
MOTHER (City)
(State or country)
MASS
6 HOLY CROSS
MALDEN
(City or Town)
Place of Burial or Cremation
DATE OF BURIAL .
NOV 20
19.4 4
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP
Received and filed
NOV 19 1532
19
(Registrar)
PARENTS
21
Informant
(Address)
97 LOWELL RD WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Julffe C. Pereaux, (Signature of Agent of Board of Health of dther)
11/19/69
(Date of Issue of Permit)
(Official Designation) /
& V.
IN RUCTIONS FOR FC. CERTIFICATE
giving IS OF DEATH d not enter nie than one a e for each ( (b) and (c)
indoes not mean de of dying, heart failure, n etc. It means diase, or compli- n. which caused
tions, if any, gave rise to cause (a), itg the under- cause last. ir
CIditions contrib- death but not e to the terminal condition given
t - Chapter 137, 1954, requires sans to print or he cause or of death on Certificates, and or 48, Acts of lequires Physi- go print or type Under signature. 1 c.
4-11-59-926662
F November 17
1962 (Year)
4 I
25 Oct
HEREBY CERTIFY,
1962.
to
17 Nov
19.
62
l last saw hemmalive on
13
Nov
, 1962
death is said to
have occurred on the date stated above, at 1:00 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Carcinoma
of Prostate
INTERVAL
BETWEEN
ONSET AND
DEATH
2 yrs
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Generalized Arteriosclerosis
Yrs
Was autopsy performed?
no
What test confirmed diagnosis ?
clinical
5 Was disease or injury in any way related to occupation of deceased ? no. If so, specify
(Signed
arthur C. Murray
M. D.
Arthur C. Murray, M.D.
(Address)
ELIZABETH
FOLEY
No.
97 LOWELL RD E
Registered No.
PHYSICIAN - IMPORTANT [(Was deceased a U. S. War Veteran, [if so specify WAR) NO
(a) Residence. No. (Usual place of abodey
3 DATE OF
DEATH
(Month)
(Day)
That I attended deceased from
(a)
ORI R-301A 1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
.
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 rugh deaths 'only as those of persons to whom they have given bedside safe Huring & 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 traumatisin (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 inost 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.
MR-301A 1
STJCTIONS OR ALCERTIFICATE
Ingiving EOF DEATH it enter rt:han one is for each ) b) and (c)
es not mean 0 of dying, s heart failure, a,etc. It means ee, or compli- which caused
lims, if any, h'ave rise to e cause (a), the under- cause last.
sitions contrib- death but not the terminal ndition given
Chapter 137, 954. requires ins to print or e cause or of death on rtificates, and 48, Acts of quires Physi- print or type der signature.
-6-59-925686
PLACE OF DEATH
Suffolk (County)
Winthrop. (City or Town)
HusTere 89-7-81
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
210
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) No.
Ave. Nursing Home.
PHYSICIAN - IMPORTANT
f(Was deceased a U. S. War Veteran, {if so specify WAR)
No
(# ABOVERS Are) Winthrop (Visual place of abode) 42 Lexington St. East Biston, Mass.
St. East Boston, mass.
Length of stay: In place of death
2. ... years ....
months.
.days. In place of residence ...
.... years.
months ..
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
F
9 COLOR
WHITE
(write the word)
10 SINGLE
MARRIED
WIDOWED WIDOWED
or DIVORCED
10a If married, widowed, or divorced HUSBAND of
(or) WIFE of
GEORGE
(Give maiden name of wife in full)
BARNES.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
Years.
Months.
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
UNKNOWN
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
WAKEFIELD, MASS
17 NAME OF
FATHER
HENRY JOHNSON
18 BIRTHPLACE OF
FATHER (City)
(State or country)
NEWBURYPORT , MASS
19 MAIDEN NAME
20 BIRTHPLACE OF
IPSWICH, MASS
(Addr
6 WOODLAWN EVERETT ,MASS
Place of Burial or Cremation
NOV. 28,
City or Town)
62
19
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ALFRED D. THOMAS
ADDRESS
4 FREMONT ST. , MATTAPAN, MASS
Received and filed 19
NOV 27 1032
(Registrar)
PARENTS
21
WELFARE DEPARTMENT
(Address) 43 HAWKINS ST. BOSTON MASS
Informant
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Malper c Sirianni f
(Signature of Agent of Board of Health/or other)
Seattle Click
11/27/62
(Official Designation) (Date of Issue of Permit)
3 DATE OF
November 22.
1962
DEATH
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY
That I attended deceased from
19.5%, to
Nov, 22
19
62
I last saw he Yalive on
NOV. 21
1962, death is said to
have occurred on the date stated above, at
2:00 A.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Pneumonia bronchial,
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
None.
Was autopsy performed ?
NO
What test confirmed diagnosis ?
Clinical.
5 Was disease or injury in any way related to occupation of deceased NO If so, specify
(Signed)
Libera
M D.
OF MOTHER
LUCY M. NEWMAN
CHARLES LIBER MAN (PRINT OR TYPE SIGNATURE) WINTHROP, MASS Date Nov. 22 19 62 MOTHER (City) (State or country)
Registered No.
To be filed for burial permit with Board of Health or its Agent.
39 GRovers (Mayflower Blanche Barnes
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