USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 9
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Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49
X
PLACE OF DEATH
Essex (County)
Denvers
(City or Town )
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
(City or Town making this return)
42.
NoDanversStateHospital .... Hathorne ..... St.
§ (If death occurred in a hospital or institution, înstea
2 FULL NAME.
( If deceased is a married, widowed or divorced woman, give also maiden name.)
255 Pleasant
St.
Hinthrop,
Mass
(a) Residence. No. ( Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years
.months 12 .days. In place of residence .......... years .......... months .......... days.
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE
( write the word)
(Month)
(Day)
(Year)
8 SEX
male
9 COLOR
white
MARRIED
WIDOWED
or DIVORCED
married
4 I HEREBY CERTIFY.
That I attended deceased from
62
19.
I last saw
.. alive on
19
death is said to
have occurred on the date stated above, 6: 00 p.m.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Arteriosclerotic heart disease
(a)
years
10a If married, widowed os diversed
Kendall
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
77
AGE.
Year
5
21
Months.
Days
If under 24 hours
.Hours ........ Minutes
13 Usual
Occupation:
Retired Bartender
( Kind of work done during most of working life)
14 Industry
or Business :
265-01-6950
15 Social Security No.
Unknown
16 BIRTHPLACE (City)
(State or country)
Norway
Virus Infection
days
Was autopsy performed ? no
What test confirmed diagnosis?
Clinical & Laborator
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
3/3/
62
ate
PARENTS
18 BIRTHPLACE OF
Unknown
FATHER (City)
(State or country )
Norway
19 MAIDEN NAME
OF MOTHER
Unknown
20 BIRTHPLACE OF
Unknown
Mass
MOTHER (City)
Unknown
( State or country )
21
Georgie T. Brimigion
Hathorne, Mass.
A TRUE COPY .
ADDRESS
Received and filed
MAR 28 1962
19
ATTEST :
(Registrar of City or Town where death occurred)
DATE FILED
March & ..
62
19
T UBV.
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town 1
3 DATE OF DEATH Due To (c) OTHER 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
ORM R-302
11110 IS A PERMANENT RECORD
X WITH UNPADING-RINGY INUSAWITH
50M-9-59-926111
DATE OF BURIAL
Winthrop Cemetery, Winthrop, 6 Place of Burial or Cremation (City or Town) March 6, 62
19
Informant
( Address)
7 NAME OF
FUNERAL DIRECTOR
Winthrop, Mass.
Alfred B. Marsh
( Registrar of City or Town where deceased resided)
Mathias E.Munsen
( Was deceased a
U. S. War Veteran,
(if so specify WAR
No
MEDICAL CERTIFICATE OF DEATH
March
3.
1962
January 19 19.
62
March 3.
to ......
.
March
3
Due Generalized Arteriosclerosis (b)
years
17 NAME OF
FATHER
Lars Munsen
WEIT
Registered No.
RECE VED
TOW
11.12
1.1-10
ILER
CI
K
6
THROT
MAR 2 81962 PM
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
IM R-301
SUCTIONS FOR AICERTIFICATE
Ingiving E)F DEATH t enter re han one sifor each >>) and (c)
as not mean S on of dying, heart failure, c. It means ed. or compli- ich caused
itis, if any, nie rise to use (a), 1g te under- use last.
ndins contrib- o Lith but not to he terminal co ition given
tes Chapter 137, of 154 requires sicos to print or cause or es death on h ce ificates, and pter 18. Acts of , retires Physi- s to rint or type eur signature.
3.6 0213
A TRUE COPY ATTEST:
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FEMALE WHITE
9 COLOR
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
11a If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 DATE OF BIRTH
13
AGE 77 Years.
.Months.
......
Days
If under 24 hours
Hours ..
Minutes
14 Usual
Occupation :
US, INTERNAL REVENUE
(Kind of work done during most of working life)
15 Industry
or Business:
CLERK
it
16 Social Security No. ...
NONE
FALL RIVER.
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
re zanel, M. D. Joseph GREGORIE
(Addres 1get washington
BROW4
6
HOLY WOOD
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
MARCH
12
1962
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP
Received and filed
MAR 12 1962
19
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME MARY C HONAN (First Name) (Middle Name) (Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.) Winthrop 25ZASNORE DRIVE
(a) Residence. No. (Usual place of abode)
months. Length of stay: In place of death .years. 7 .days. In place of residence.
45 years
... months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
10
196 2
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
19€/ 1
maria 10
I last saw her alive on Marche 6 , 1962 death is said to
have occurred on the date stated above, at
7:04 1 m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
myocardial Hear
INTERVAL BETWEEN ONSET AND DEATH
Due To
(b)
arteriosclerosis. com
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
failaire
Cancestive
months
Was autopsy performed?
What test confirmed diagnosis?
17 BIRTHPLACE (City)
(State or country)
ILLESS.
18 NAME OF
FATHER
JOHN J HONAN
19 BIRTHPLACE OF
FATHER (City)
(State or country)
MASS.
WAREHAM.
20 MAIDEN NAME
OF MOTHER
CHRISTINE MURPHY
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
B 1 ..
22
Informant
(Address)
252 SHORE DRIVE 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)
(Official Designation)
(Date of Issue of Permit) /
43
PHYSICIAN - IMPORTANT [ ( Was deceased a {U. S. War Veteran,
[if so specify WAR) NO
St.
(If nonresident, give city or town and State)
PLACE OF DEATH
X SUFFOLK. (County)
1 WINTHROP (City or Town) Nul BAY VIEW REST HOME 140 WASH AVES.
To be filed for burial permit with Board of Health or its Agent.
PARENTS
(Print or Type Name) 3/10 .62
PROVIDENCE
GENEVIEVE MCALEENAN
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
( )
...
.1 .... 6.
ROP
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.
MAR 1 21962 FM
M R-302 1
MARGIN RESERVED FOR BINDING V UMAVA ANA - IMIS IS A PERMANENT RECORD
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 (c)
25M-8-56-918227
X PLACE OF DEATH
Essex
(County)
Lynn
(City or Town)
Lynnview Hospital No.
§(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
2 FULL NAME Elizabeth Snook (McQuillan.)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence.
37 Temple Ave
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.
.......
.years.
4
.months.
„days. In place of residence.
... years ..
months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
March .... 13, 1 962
(Month) (Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
Nov.24
1961,
to .....
Mar. 13/62
19
I last saw heralive on
Mar 13/62, 19.
death is said to
have occurred on the date stated above, at
2:45 D
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Metastasis, generalized ---
INTERVAL BETWEEN ONSET AND DEATH 5 mos.
(1)) Due ToCarcinoma of Sigmoid
1 yr
OTHER
SIGNIFICANT
CONDITIONS
Hypothyroidism
yrs.
Was autopsy performed?
no
What test confirmed diagnosis ?...
colostomy
5 Was disease or injury in any way related to occupation of deceased ?.... NO If so, specify
(Signed)
Clarence London
M. D.
(Address)
Lynnview Hosp ..
Date.
3/13/68
Fishkill Cem.
Fishkill, N .Y
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
March 17. 62
19
7 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS
Winthrop, Mass.
Received and filed.
MAR 30 1962
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
fe
9 COLOR
wh
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
wid.
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ..
Aaron
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
79Years
1
Months.
.22 Days
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 .... none
Last Boston
16 BIRTHPLACE (City)
(State or country)
Mass.
17 NAME OF
FATHER
John J. McQuillan
18 BIRTHPLACE OF
FATHER (City) ..
E. Boston
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Virginia A. Strong
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
c/n/b/1
21
John Snyder
Informant
(Address)
37 Temple Ave., Winthron
A TRUE COPY
Albert Y. Alsme
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Mar. 20/62
19
6.13.
Registered No.
44
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Lynn
(City or Town making this return)
PARENTS
(Was deceased a
U. S. War Veteran,
if so specify WAR).
Winthron
St
(write the word)
RECE VED
TO
1
5
THROP
MAR 3 01962 AM
X
PLACE OF DEATH
Essex
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Lynn
(City or town making return)
Registered No.
45
§(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
19 Johnson Avenue
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years ...........
... months
.. days. In place of resideDe.
.... years ..
.. months ..
........
... days.
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
19 COLOR
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the bord)
Roberta K. O'Donnell
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13 48 10 17
AGE Years ....
Months
Days
Hours ........ .. Minutes
Date and hour of injury 19
Manager
14 Usual
Occupation :
(Kind of work done during most of working life)
15 Industry
or Business :
024-03-04:04
16 Social Security No.
E. Boston
17 BIRTHPLACE (City) (State or country)
Moss.
18 NAME OF
FATHER
Peter W. Edwards
PARENTS
19 BIRTHPLACE OF
FATHER (City) (State or country)
Newfoundland
20 MAIDEN NAME
OF MOTHER
Margeret M. Drew
E. Boston
21 BIRTHPLACE OF
MOTHER (City)
(State
country Roberta K. Edwards
Mass ..
Holy Cross Cem. Malden, Mass
Place of Burial, or Cremation.
March 20, 1962
19
(Cito of Town)
8 NAME OF FUNERAL DIRECTOR Richard .C.Kirby, Inc
ADDRESS 917 Bennington St. E.Boston
Received and filed
MAR-3.0 1962
19
(Registrar of City or Town where deceased resided)
A TRUE COPY!
ATTEST
(Registrar of City or Town where death occurred)
DATE FILED
Mar 20/62
............ 19 ..
V.BV
THIS IS A PERMANE
WALAG PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK DU
R-305 1
Lonn)
(City or Town)
DOA Lynn Hospital
Laurence J. Edwards
No. 2 FULL NAME (a) Residence. No. (Usual place of abode) MEDICAL CERTIFICATE OF DEATH March 17, 1962 3 DATE OF DEATH (Month) 5 Accident, suicide, or homicide (specify) Where did Injury occur ? (City or town and State) (Specify type of place) Manner of Nature of Injury If so, specify (Signed) 7 DATE OF BURIAL 25M-4.59-925100 Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, (i. L.) the time of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided If accidental, was injury causally related to the death ?
Did injury occur in or about home, on farm, in industrial place, or in public place ?
Injury
(How did injury occur ?)
7
While at work ?
Was autopsy performed ?
.no
6 Was disea
Eanund az wayglued pocoupation of deceased?
(Address)
181 N. Common St. Lynn 3/17/62
f(Was deceased a
U. S. War Veteran,
WW II
{if so specify WAR)
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are Suldeff deaths inpresumably coronary occlusion.
(Day)
(Year)
lla If married, widowed, or divorced HUSBAND of
If under 24 hours
First National Stores
22 Informant
19 Johnson Ave . . Winthrop,Mass (Address)
RECEIVED
TO!
11.12.
-1
6
A
TROR
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
·MAR-3-01962 AM
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-301A 1
[ CTIONS
ERTIFICATE
ving
F DEATH enter clan one For each ) and (c)
not mean of dying, ut failure, . It means a or compli- ch caused
if any, rise to se (a), under- last.
ase dibis contrib- deh but not to e terminal concion given
pter 137, 19 requires an he o print or ause or leath on ertuates, and Acts of equi's Physi- pet or type nde gnature.
R 0 1962
PLACE OF DEATH
Suffolk
(County)
Winthrop
STANDARD CERTIFICATE OF DEATH
Registered No.
46
[{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, fif so specify WAR)
2 FULL NAME
Fannie (Holland) Scott
(If deceased is a married,, widowed or divorced woman, give also maiden name.)
154 Bowdon Street
St.
( If nonresident, give city or town and State)
Length of stay : In place of death ........ .. years.
1
months ..
.... days. In place of residence.
.. years
30
months ...
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
March
17.
19.62
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
Feb. 18
19 .. 56
to
March ... 17,
19
62
I last saw he.lalive on
March .... 15
19 .... 62, death is said to
have occurred on the date stated above, at
1:30 a.m.
INTERVAL
BETWEEN
ONSET AND
DEATH
5 yrs
83
12
AGE ..
Years
3
Months.
1
Days
If under 24 hours
Hours ....
.Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
Own home
or Business :
15 Social Security No. None
16 BIRTHPLACE (City)
(State or country)
England
Was autopsy performed?
What test confirmed diagnosis? Clinical & laboratory
5 Was disease or injury in any way related to occupation of deceasedino If so, specify
(Signed)
MiTraunstein
M. D.
M. Traunstein, Jr. ,M .D.
(PRINT OR TYPE SIGNATURE)
(Address)
73 Bartlett Rd.
Date.
March 19, 62
6
Garden Cemetery
Chelsea, Mass
(City or Town)
Place of Burial or Cremation
DATE OF BURIAL
March 20
1962
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS
Winthrop, Mass
Received and filed march 20, 1962
(Registrar)
PARENTS
17 NAME OF
FATHER
John Holland
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Elizabeth Cabel
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
21 Harry A Scott
Informant
(Address)
154 Bowdon St. Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me/ BEFORE the burial or transit permit was issued: Trable Percance (Signature of Agent of Board of Health or other), Health Mua 3/20/67
(Official Designation)
(Date of Issue of Permit)
MARRIED
WIDOWED
or DIVORCEDIarried
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Harry A Scott
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
Due TGeneralized arteriosclerosis. (b)
8 yrs
Due TCerebral arteriosclerosis (c)
2 yrs
OTHER
SIGNIFICANT
CONDITIONS
Diabetes mellitus
2 yrs
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
(a) Residence. No. (Usual place of abode)
SENSI METHOD
Town ) Promete 142 Pleasent Street
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
To be filed for burial permit with Board of Health or its Agent.
No.
1-6-325686
no
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic & hypertensive
(a)
heart disease
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
MAR 2 01982 TH
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.
[ R-301
ICTIONS IR ERTIFICATE
ving 3 DEATH n enter an one efor each () and (c)
do not mean de of dying, Art failure, €. It means se or compli- with caused
ion if any, ga rise to @se (a), &under- care last.
ditis contrib- deh but not o 1: terminal comion given
e :- hapter 137, of 14 requires ciar to print or the cause or S o death on cemicates, and ter , Acts of req res Physi- to Ent or type und signature.
-61-93 13
A TRUE COPY ATTEST:
(Registrar)
PARENTS
18 NAME OF
FATHER
JAMES CARROLL
19 BIRTHPLACE OF
FATHER (City)
(State or country)
IRelAnd
20 MAIDEN NAME
OF MOTHER
MARY GRIFFIN
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
New BRUNS wick
22 Informant
JAMES P. CARROLL (Address) SMOORE St. E. BOSTON
7 NAME OF
DIREC
Frederick J. MAGRATH
ADDRESS
EAST Boston
Received and filed
MAR 20 1962
.. 19.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
11a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Husband's name in full)
12 DATE OF BIRTH
77
13
AGE ..
Years.
Months ...........
.. Days
If under 24 hours
Hours ..
Minutes
14 Usual
Occupation :
LAboRER
(Kind of work done during most of working life)
15 Industry
or Business :
Retired
16 Social Security No.
ONDI
Charlestown
17 BIRTHPLACE (City)
(State or country)
MASS
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
a. Nathan Capteur
M. D.
A. NATHAN CAPIAli
(Print or Type Name)
(Address)
186 PrincetoNIE Bi
Date. Mat. 19 1962
Holy Cross 6 Place of Burial or Cremation
Malden
(City or Town)
DATE OF BURIAL MARCH 21 1962
-
PLACE OF DEATH ......
X Suffolki
locsten 2-7-9-4
CENSE PET
Winthrop (City or Town) Mount's Convalescent Home
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.
2 FULL NAME John. (First Name) (Middle Name) (Last Name)
A. CARROLL
[ (Was deceased a
U. S. War Veteran,
No
(If deceased is a married, widowed or divorced woman, give also maiden name.) 15 Moore
St.
EAST Boston
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death. .years .. months. .. days. In place of residence.
10 years.
......
... months .........
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
liarch
18
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
March 101962
to
That I attended deceased from
19
I last saw himalive on were?
1,92
death is said to
have occurred on the date stated above, at
11:45Pm.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Cardiare Decompensation
(a)
Due To
Chronic lyocarditis
(b)
Due To
(c)
carcinomatosis primary
OTHER
SIGNIFICANT
rt. lower lung
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
INTERVAL BETWEEN ONSET AND DEATH
Registered No.
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(if so specify WAR)
(If nonresident, give city or town and State)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Galble . Terrains x Signature of Agent of Board of Health for other) Health Office 3/20/68
(Official Designation)
(Date of Issue of Permit)
1 (County)
1
-
(Give maiden name of wife in full)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT SERVICE NUMBER
6
RULES OF PRACTICE MAR 2 01962 TM
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.
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