Town of Winthrop : Record of Deaths 1963, Part 12

Author: Winthrop (Mass.)
Publication date: 1963
Publisher:
Number of Pages: 574


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 12


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54


E. Boston,


8


FULL


NAME


Ralph Imbrici


St.


FETAL DEATH


EXTRACTS OF CERTAIN SECTIONS OF TOWi


OF CHAPTER, 46 AS AMENDED OR ADDED BY CHAPTER 48. 1. ACTS OF 1960. IFFI- FLERE


Section 2A. "Examination of records and returns of illegitimate.births, or abnormal sex births, or fetal deaths, ... shall not be permitted except ... ".


6


Section 9A. When a child As porn dead, after a period of gestation of not less than twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and no movement of voluntary muscle the physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.


Section 12. . No birth record of a child born out of wedlock or of a child of abnormal sex, and no record of fetal death shall so be transmitted to any other city or town."


Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.


RM R-302


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 THIS IS A PERMANENT RECORD


PLACE OF DEATH


Essex


(County)


Danvers


(City or Town)


No.


Danvers State Hospital, Hathorne


S(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)


William H. Frizzell


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a)


Residence. No.


56 Main


(Usual place of abode)


2


10


18


Length of stay: In place of death.


.years ....


month


days. In place of residence .......... years .......... months .......... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


March


19,


1963


(Month)


(Day)


(Year)


I HEREBY CERTIFY,


April 30,


61


). 19 ..


That I attended deceased


March 19.


19


63


I last saw h.mluve on


March 19


6, death is said to


have occurred on the date stated above, at


m.


INTERVAL BETWEEN ONSET AND


(a)


...


Arteriosclerotic heart disease (b)


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


Willard M Hausman


(Signed)


Willard M


Hausman


M. D.


(Address)


Hathorne, Mass.


Date.


3/20/


1. 63


19.


Winthrop Cemetery, Winthrop


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


March 22,


63


19.


7 NAME OF


FUNERAL DIRECTOR


Maurice Kirby


ADDRESS


Winthrop,


Mass.


Received and filed


APR 4 1963


19


(Registrar of City or Town where deceased resided)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


white


10 SINGLE


MARRIED


WIDOWED


DIVORCED married


UNKNOWN


11 If married, wModlinieceReed HUSBAND of


(or) WIFE of.


(Husband's name in full)


12


80


7


28


If under 24 hours


Hours ........ Minutes


Steamfitter


13 Usual


Occupation :


(Kind of work done during most working life)


14 Industry


or Business :


Not Determined


15 Social Security No ..


Unknown


16 BIRTHPLACE (City)


(State or country}


Caneda


17 NAME OF


FATHER


David Frizzell


PARENTS


18 BIRTHPLACE OF


Unknown


FATHER (City).


(State or country)


Canada


19 MAIDEN NAME


OF MOTHER


Emily Oakes


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Paris


France


Mary F. Sheehan


21 Informant


(Address)


Hathorne, Mass.


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


DATE FILED


March .... 21,


1963


TVRV


1


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF TEM TONIE CERTIFICATE OF DEATH


Danvers


(City or Town making this return)


Registered No.


56


(Was deceased a


U. S. War Veteran,


No


Winthrop,


(if so specify WAR, .. Mass.


St


(If nonresident, give city or town and State)


(write the word)


male


to


3:30a


(Give maiden name of wife in full)


AGE


Years.


Months.


Dayı


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Bronchopneumonia (Right SidePeATH


50M . 10.61.931673


2 FULL NAME


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


OF TOW


SERVICE NUMBER


OFFICE.


3


LERK


6


THROR


APR :41963 AM


FORM R-301


d for burial permit Board of Health its Agent. STRUCTIONS FOR AL CERTIFICATE


T OR TYPE : OR CAUSES DEATH not enter re than one se for each ). (b) and (c)


does not mean ode of dying, s heart failure, 2, etc. It means ease, or compli- which caused


itions, if any, h gave rise to e cause (a), ag the under- cause last.


nditions contrib- o death but not to the terminal condition given


m.C.


PLACE OF DEATH


Suffolk ..... (County)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


(City or Town making this return) .....


1


Winthrop


(City or Town)


No


42 Pearl Ave. , Winthrop, Mass. St. ( give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


2 FULL NAME.


(If deceased is a married, widowed or divorced woman, give also maiden name.)


42 Pearl Ave.


(a) Residence. No ...


(Usual place of abode)


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


DIVORCED


UNKNOWN


(write the word) married


(Month)


(Day)


(Year)


4 IHEREBY CERTIFY, That I attended deceased from


....


1 en.


19


50


.. , to ... March 24 19 63


I last saw himlive on


MARCH 21, 1963


death is said to


have occurred on the date stated above, at


livs A.m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Coronary Occlusi


1 hour.


18 months


13 Usual


Occupation :


salesman


(Kind of work done during most working life)


14 Industry Sundries & peper


or Business :


O11-09-5893


15 Social Security No


16 BIRTHPLACE (Ciposton (State or country) E


17 NAME OF FATHERRalph Turransky


18 BIRTHPLACE OF FATHER (City) (State or country)


Russia


19 MAIDEN NAME OF MOTHERAnnie Finn


20 BIRTHPLACE OF MOTHER (City). (State or country)


Russia


wife Ruth Turrensky


21 Informant


(Address)


42 Pearl Ave Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death was ,fuled with me BEFORE the burial or transit permit was issued:


(Signature of Agent of Board of Health or other) Health Effects


march 2.5 1963


(Official Designation)


(Date of Issue of Permit)


-62-932382


A TRUE COPY ATTEST:


3yrs.


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


(Signature)


Charles Liberman.


M. D.


CHARLES


LIBERMAN


PARENTS


(Address)


WINTHROP, MASS Date.


Print or Type Name)


3/24/1963


Sharon Memorial Park Sharon 6


Place of Burial or Cremation


24 March


.. 19


(City or Town) 63


DATE OF BURIAL


7 NAME OF


FUNERAL DIRECTOR


Benj. F. Solomon


ADDRESS


420 Harvard St. Brookline


Received and filed


MAR 25 1963


19


(Registrar)


11 If married, widowed, or divorce HUSBAND of Ruth Epstein


(or) WIFE of


(Husband's name in full)


12


AGE


52


.Years.


Months .....


.Days


If under 24 hours


.. Hours ........ Minutes


Hypertensive. Coronary


(b)


ARTERY Ht. Disease.


Due To


(c)


OTHER


DIABETES MELLITUS.


CONDITIONS


24 1963


Winthrop


St


(Was deceased a U. S. War Veteran, (if so specify WAR)


no


[(If death occurred in a hospital or institution,


Abraham


Harold Turransky


STANDARD CERTIFICATE OF DEATH


Registered No. .......... .......


(If nonresident, give city or town and State)


3 DATE OF


DEATH


MARCH


INTERVAL


BETWEEN


ONSET AND


DEATH


(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


TOO


THE


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance 00 0e2 51963 PM 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 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.


-


PLACE OF DEATH


Suffolk (County)


Winthrop


(City or Town)


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. 58


f(If death occurred in a hospital or institution,


St. ¿ give its NAME instead of street and number)


2 FULL NAME


Eleanor L. Waggett


(McGurn)


(Was deceased a


U. S. War Veteran,


[if so specify WAR)


No


95 Main Street, Winthrop


St.


(If nonresident, give city or town and State)


12


Length of stay: In place of death .years months .. days. In place of residence. .12 .. years


.... months ............ days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


March


25


1963


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


19


.. , to.


19


That I attended deceased from


I last saw h ........ alive on


19 ..


death is said to


have occurred on the date stated above, at


3:45 P. m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Death presumably due to


(a)


INTERVAL BETWEEN ONSET AND DEATH


Due Tonatural CAUSES, namely (b)


generalized and coronary


Due To artery arteriosclerosis .! (c) complicated by diabetes


OTHER SIGNIFICANT CONDITIONS viellitus of yours duration


Was autopsy performed?


Winthrop Board of Health


What test confirmed diagnosis?


Charles Liberaway MM


5 Was disease or injury in any way related to occupation of deceased? If so, specify


(Signed)


CHARLES LIBERMAN


(Print or Type Name)


(Address) WINTHROP Date. 3126/ 1965


Holyhood Cemetery, Brookline


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


March ... 28th


1963


7 NAME OF


FUNERAL DIRECTOR


Richard C. Kirby, Inc


ADDRESS917 Bennington St. ,E.Boston


Received and filed


MAR 26 1963


19


(Signature of Agent of Board of Health or other)


A).auch.26,1963


(Official Designation)


(Date of Issue of Permit)


T V.B.V


TRUCTIONS FOR L CERTIFICATE


giving : OF DEATH not enter e than one e for each , (b) and (c)


does not mean de of dying, heart failure, , etc. It means ase, or compli- which caused


ions, if any, gave rise to cause (a), the under- cause last.


ditions contrib- death but not to the terminal condition given HI.C.


e :- Chapter 137. of 1954 requires cians to print or the cause or % of death on certificates, and :er 48, Acts of requires Physi- to print or type under signature.


-61-930213


A TRUE COPY ATTEST:


(Registrar)


PARENTS


18 NAME OF


FATHER


Owen McGurn


19 BIRTHPLACE OF


FATHER (City)


(State or country)


Ireland


20 MAIDEN NAME OF MOTHER Mary Morrow


21 BIRTHPLACE OF


MOTHER (City)


(State or country)


Ireland


22


Miss Catherine B. Waggett-dau.


Informan


95 Main 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: Kaiph E


Boston


17 BIRTHPLACE (City) (State or country) Mass.


If under 24 hours Hours. ...... .Minutes


14 Usual


Occupation :


.....


Housewife


(Kind of work done during most of working life)


15 Industry


or Business:


At home


16 Social Security No.


None


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


Andrew J.


Waggett


(Husband's name in full)


12 DATE OF BIRTH


Sept.6,1870


13


AGE.


9.2Years ..


6


Months.


.19 ... Days


9 COLOR


White


10 CITIZEN


OF U.S.


8 SEX


Female


(Last Name)


(First Name) ( Middle Name) (If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No. (Usual place of abode)


PHYSICIAN - IMPORTANT


95 Main Street, Winthrop


No.


M R-301 1


M. D.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE.


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


MOI


OF


THROI


RULES OF PRACTICE MAR 2 61963 AM


The fulfillment of the purpose of these laws calls for the observance 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 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.


ORM R-301


for burial permit bard of Health its Agent. TRUCTIONS FOR CERTIFICATE


OR TYPE OR CAUSES DEATH not enter than one e for each (b) and (c)


does not mean de of dying, heart failure, etc. It means ise, or compli- which caused


ions, if any, gave rise to cause (a), the under- cause last.


ditions contrib- death but not o the terminal condition given


C


PLACE OF DEATH


Suffolk (County)


.OVIETEM


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


Registered No. 59


[(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)


(a)


Residence. No ...


2 Washington Terrace


St


(Usual place of abode)


(If nonresident, give city or town and State)


Length of stay: In place of death years months ........ days. In place of residence 87 years 2 months days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


10 SINGLE


(write the word)


MARRIED Married


WIDOWED


DIVORCED


UNKNOWN


Male


White


11 If married, widowed, or-divorced


HUSBAND of


Alice Abbott Munday


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


12


AGE81 .. Years .. 2 ...... Months2.0.


.Days


If under 24 hours


Hours ........ Minutes


reared office Mgr


(Kind of work done during most working life)


14 Industry


or Business :


General Electric Co.


15 Social Security No ...


01-205-3423-A


16 BIRTHPLACE (City) .....


winthrop


(State or country)


massachusetts


17 NAME OF


FATHER


John Wood ry Davison


18 BIRTHPLACE OF


FATHER (City)


Gloucester


(State or country)


Massachusetts


19 MAIDEN NAME


OF MOTIIER


Tovicy White


20 BIRTHPLACE OF


MOTHER (City)


Plymouth


(State or country)


Vermont


21 Informant


Mrs .... Alice Davison


( Address) 2 Washington Terrace, Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: faith 18 Serianni (3)


(Signature of Agent of Board of Health or other)


Health Officie


1/2011, 1963


....


(Registrar )| (Official Designation)


(Date of Issue of Permit)


TYPV


A TRUE COPY ATTEST:


3 DATE OF


March 29


1963


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY, That I attended deceased from


Sept ......... 1 ..... , 19.6.0 ..... , to.March ..... 29


19 .. 6.3


I last saw KLMlive on March ..... 2.7.


16.3 .. , death is said to


have occurred on the date stated above, at


5:30am


n.


INTERVAL


BETWEEN


ONSET AND


DEATH


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


heart


disease


(a) .Arteriosclerotic


3 yrs


Due To


Generalized


(b)


arteriosclerosis


5 yrs


(c)


Due To


Parkinsons disease


5 yrs


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


no


What test confirmed diagnosis? clinical & lab


5 Was disease or injury in any way related to occupation of deceased ..... If so, specify


(Signature)


M. Traunstein


M. D. M. Traunstein, Jr. V.M. D.


(Print or Type Name)


(Address)


73 Bartlett Rd


3-30


163


Winthrop Cemetery Winthrop, Lass. 6 Place of Burial or Cremation (City or Town)


DATE OF BURIAL


7 NAME OF


FUNERAL DIRECTOR


alfred th March


ADDRESS


174 Wintifop Street, Winthrop


Received and filed


APR 1 1963


19


62-932382


I


Winthrop (City or Town)


No. Mount Convalescent Home, Inc.


Roland Erle Davison


2 FULL NAME.


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(City or Town making this return)


PARENTS


April 1,1963


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE.


RECE VED


RANK, RATING


TOM


ORGANIZATION AND OUTFIT


SERVICE NUMBER


-1


6



RULES OF PRACTICE


YTHROR


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 a's those of pensons to whom they have given bedside care during a lan illness from disease fun- 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 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.


M R-303


1


(County) WINTHROP


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


(City or Town making this return) .....


MEDICAL EXAMINER'S CERTIFICATE OF DEATH


Registered No.


60


304 Pleasant St.,


[(If death occurred in a hospital or institution,


St. ¿ give its NAME instead of street and number)


No.


2 FULL NAME


(First Name)


(Middle Name)


(Last Name)


[(Was deceased a


U. S. War Veteran,


(if so specify WAR)


(If deceased is a married, widowed or divorced woman, give also maiden name.) 304 Pleasant St., Winthrop


(a) Residence. No.


(Usual place of abode)


(If nonresident, give city or town and State)


Length of stay: In place of deathyears months days. In place of residence 35 years months days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


March


29,


1963


9 SEX


10 COLOR


white


11 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN


(write the word)


married


(Month)


(Day)


(Year)


4I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : (If an injury was involved, state fully.)


12 If married, widowed, or divorced HUSBAND of Effie.


ae Poolen


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


5 Accident, suicide, or homicide (specify)


Date and hour of injury


retiredUsalerk 19.


.....


(Kind of work done during most of working life)


15 Industry


Business : .....


(City or town and State)


Did injury occur in or about home, on farm, in industrial place, or


public place ?


(Specify type of place)


Manner of


Injury


(How did injury occur ?)


Nature of Injury


While at work? Was autopsy performed ...


6 Was disease of injury in any way related to occupation of deceased ?


(Signed)


Michael


Luongo ,M.D.


Boston ( Print or Type Name)


Date 3/301963


7 Grove Cem tery Fre port, Maine


l'lace of Burial or Cremation. (City or Town)


8 NAME OF


FUNERAL DIRECTOR


DATE OF BURIAL April 3 1963 alfred B. March


ADDRESS 1.74Winthrop St.Winthrop


Received and filed


19


A TRUE COPY ATTEST:


(Registrar)


PARENTS


18 NAME OF FATHER George Sherman O'Malley


Lowell 19 BIRTHPLACE OF FATHER (City) (State or country) Massachusetts


20 MAIDEN NAME OF MOTHER Georgia Anna Murch


21 BIRTHPLACE OF


M. D. MOTHER (City) (State or country)


Maine


22 Informant Urs. Carle F. O'malley


(Address)


304 Pleasant St. Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial ør transit permit was issued : Mass. Parphil Vivienne (B)


ASignature of Agent of Board of Health or.other) Health Effects


(Official Designation (Date of Issue of Permit) V


· If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. §§ 44-48.


100M - 3-62-932695


PLACE OF DEATH


SUFFOLK


I for burial permit oard of Health its Agent.


N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF


ACUTE MYOCARDIAL INFARCTION


13 AGE 59 Years ........... .. Months. KOD ....... Days


If under 24 hours Hours Minutes


IF ACCIDENTAL, was injury causally related to the death ? Where did Injury occur ?




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