USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 18
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FATHER
Frank Arnoldson
PARENTS
18 BIRTHPLACE OF
FATHER (City)
Waltham
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Doris 0'Neil
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
South Hadley
Massachusetts
Records at the
21 Informant
Wrentham State School
( Address)
Wrentham, Massachusetts
A TRUE COPY
ATTEST :
(Registrar of City or Town where death occurred)
DATE FILED
April 3, 1963
.19
(Registrar of City or Town where deceased resided)
1
. .
-
:
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
March
31
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
March
31
41
March 31
83
I last saw
er
.alive on
March 31
63
19
.. , death is said to
have occurred on the date stated above, at
3:40 p
nı.
INTERVAL BETWEEN ONSET AND
Due To
(b)
Pulmonary abscess
(L.U.L. )
(? I.B.C.)
Due To Circulatory Malformations congenita (c)
OTHER
SIGNIFICANT
CONDITIONS
Cyanosis
Was autopsy performed?
Yes
What test confirmed diagnosis ?
Clinical & Autopsy
No
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
Wiggin L. Merrill
M. D.
(Address)
Wrentham, Mass.
Date ...
Apr.1
63
19
Mt. Auburn Crematory, Cambridge, Mass. 6
l'lace of Burial or Cremation
(City or Town)
DATE OF BURIAL
April 3,
19
63
7 NAME OF
FUNERAL DIRECTOR
Short & Williamson, Inc.
ADDRESS 52 Trapelo Road, Belmont, Mass.
Received and filed
MAY 2.9 1963
19
50M - 10-61-931673
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
Norfolk
Wrentham
(City or Town making this return)
(Was deceased a
U. S. War Veteran,
No
( if so specify WAR,. Winthrop, Massachusetts
19
to ....
19.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Bronchopneumonia (Left)
(a)
months
(Give maiden name of wife in full)
If under 24 hours
.Hours ........ Minutes
Day?
Boston
. .
:
(County)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
..
6
20
THROP.
MAY 2 91963 AM
{
PLACE OF DEATH
SUFFOLK
(County)
BOSTON
(City or Town)
No. .................................
.......
....... ...................
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
WN
To be filed for burial permit with Board of Health or its Agent.
85
(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.)
58 Birch Road, ...
... Winthrop., .. Massachusetts
(If nonresident, give city or town and State)
Length of stay: In place of death. .years. months .. days. In place of residence. .years .. .. months ... .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
April
1.
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That
attended deceased from
March 22, 19 63
to ....
April
1
1963
wdast saw h.O.lalive onA.p.r.i.l ...... ]
19 ... 6 .. 3, death is said to
have occurred on the date stated above, at
7.50am
INTERVAL BETWEEN ONSET AND DEATH
12 DATE OF BIRTH
3 days 13
55
AGE .........
Years .............. Months ............ Days
If under 24 hours
... Hours .............. Minutes
Due To
(bHemorrhagic Diathesis
1 mo
Due To Idiopathic Thrombocyto-
(c) penic Purpura
OTHER
SIGNIFICANT
Obesity
CONDITIONS
....
Was autopsy performed?
Yes
17 BIRTHPLACE (City)
(State or country)
NewYork, ......
What test confirmed diagnosis?
Aut; op.s.y.,
S Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
M. D.
Charles.L ... Clay,. M. D.
(l'rint or Type Narne)
(Address)
Ass's. Die. Hans Con'%, Keep, DaApril 1, 19 63
PARENTS
6 Staro Konstandine(Lebanon) W.Roxbury
Place of Burial or Cremation
DATE OF BURIAL
April ... 2,
.19 63
7 NAME OF
FUNERAL DIRECTOR
Benjamin F.Solomon
ADDRESS
120 Harvard Street, Brookline
Recelyed and fled
APR ........ 2 ... 1953
-19
(Signature & Agent of Board of Health or other)
6006/22
50-1-63
A TRUE COPY ATTESTI
18 NAME OF
FATHER
Joshua H.Gordon
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
20 MAIDEN NAME
OF MOTHER
Clara R.Dinn
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Germany
22
$% Barry I. Tulin
Informant
(Address)
58 Birch Road, Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Official Designation)
(Date of Issue of Permit)
T
NSTRUCTIONS FOR CAL CERTIFICATE
In giving SE OF DEATH do not enter ore than one use for each a), (b) and (e)
's does mat mean mode of dying, as heart failure. sia, etc. It means isease, or campli- s which caused .
ditions, if any, ich gave rise to ve cause (a). ing the under- cause last. M C.
'anditions contrib- to death but not I to the terminal e canditiont given
296 ote :- Chapters. s of 1954 Quires micians to print or e the cause or ses of death on th certificates, and pter 48, Acts of ), requires Physi- as to print or type le under signature AY 14 1963 pal Directen lise use only JACK Ink.
13.61-930213
ORM R-301 1
....
....
Registered No.
3665-
2 FULL NAME Holon W Tulin, (First Name) (Middle Name) (Last Name)
8 SEX
female
white
9 COLOR
10 CITIZEN
OF U.S.
YES 19
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
Mischa Tulin
14 Usual
Occupation :
Piano Teacher
(Kind of work done during most of working life)
8 YES
15 Industry
or Business:
unk yrs
16 Social Security No.
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Intraperitoneal Hemorrhage
Charles it mackie
(Registrir)
(City or Town)
(a) Residence. No. (Usual place of abode)
Massachusetts General Hospital BAKER MEMORIAL
A TRUE COPY ATTEST:
Charles it Mackie City Registrar
6
THROW
MAY 2 41963 AM
FORM R-301
d for buriaf permit Board of HenIth 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, I heart failure. 1, etc. It means ease, or compli. which caused
itions, if any, gave rise to : cause (a). If the under- cause last.
editions contrib. o death but not to the terminal condition given nº C.
Directon use only CK Ink. l{ 14 1963 62-932382
PLACE OF DEATH
SUFFOLK
(County)
I
BOSTON
(City or Town)
Ofe Gantmonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
03750
Registered No.
S(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME
Albert ... L ... Day.
(If deceased is a married, Widowed or divorced woman, give afso maiden name.)
64 Lincoln Street
Winthrop, Mass.
St.
(a) Residence. No ..... (Usuaf 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 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
4 I HEREBY CERTIF
March
28
19
63
to
inthat Je attended deceased, from V
19
11 lf married, widowe HUSBAND of Elgia Mackay
(or) WIFE of.
(Husband's name in full)
2 AGE. 82 Years. .Months ......... .Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Railroad worker
( Kind of work done during most working life)
14 Industry
or Business:
Railroad
un'k yrs Social Security No ...
16 BIRTHPLACE (City) ... (State or country) New Hampshire
PARENTS
17 NAME OF
FATHER
Information Unavailable
18 BIRTHPLACE OF
FATHER (City)
(State nr country)
Information Unamailable
19 MAIDEN NAME
OF MOTHER
Information Unavailable
20 BIRTIfPLACE OF
MOTHER (City)
(State or country)
Information Undwilable
Elgie M. Day
21 Informant
( Address)
64 Lincoln St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was aled with me BEFORE the buriaf or transit permit was issued: Jacqueline Daral (Signature of Agent of Board of Health or other)
16 00 8
4/3/63
(Official Designation) (Date of 1 ue of Permit) TX
A TRUE COPY ATTEST:
INTERVAL BETWEEN ONSET ANO DEATH unk yr
Due To (b)
Due To (c)
OTHIER
Cor Pulmonale
SIGNIFICANT
CONDITIONS
Was autopsy performed?
Yes
What test confirmed diagnosis ?
Autopsy
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
@hillary
M. D.
Charler.L."ClayphiPor Type Namey
Apr. 2 63
...........
19 (Address)es'r. Dr., Mass. Can't. Hosp." Winthrop Cemetery Winthrop 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL April 4
1963
7 NAME OF
FUNERAL DIRECTOR
Ernest P. Cation
ADDRESS 147 Windhoy St. Wasthe.
SAPR 4 1963 19
Received and ffed
Charles it mackie
(Registrar)|
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
no
3 DATE OF
DEATH
April
2
1963
(Month)
(f)ay)
(Year)
We I last saw Himlive on
.April
2
19 ... 63death is said to
0
(Give maiden name of wife in full)
have occurred on the date stated above, at 4:30a.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Pulmonary Emphysema
NMASSACHUSETTS GENERAL HOSPITAL
434.1 82 × 20
A TRUE COPY ATTEST: Charles it Mackie
City Registrar
TO:
6
THROP
MAY 1 41963 AM
1
1
Boston
(City or Town)
KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return) 03749
Registered No.
[(If death occurred in a hospital or institution,
.St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME.
Baby Boy Dunne
(If deceased is a married, widowed or divorced woman, give also maiden name.)
914A Shirley
Winthrop
(a) Residence. No ...
(Usual place of abode)
Length of stay: In place of death.
20 hrs ..
.. months
days.
45 min In place of residence ......... years .......... months .......... clays.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
White
10 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
(write the word)
Single
11 If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of ..
(Husband's name in full)
12
AGE .......... Years ..........
.. Months ...... ..
.Days
11 under 24 hours
20 Hours 45 Minutes
13 Usual
Occupation :
( Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No. .
none
16 WIRTHPLACE (City)
(State or country)
mars
17 NAME OF
FATHER
Robert Dunne
18 MIRTHPLACE OF
FATHER (City)
(State or country)
Boston
Mais
19 MAIDEN NAME
OF MOTHER
Sharon Knox
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Mars
21 Informant
Robert Dunne
(Address)
914 A Shirley St Hanteras
I HEKEBY CERTIFY that a satisfactory standard certificate of death was/filed with me BEFORE the burial or transit permit was issued: Jacqueline Durata
(Signature of Agent of Board of Health or other)
16009
11/3/63
·1.
(Registrar)|| (Official Designation)
(Date of Issue of Permit)
X
A TRUE COPY ATTEST:
PARENTS
Winthrop 6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Afx 4
43
7 NAME OF
Eineittlaggiano 147 Wertherof St Winthrop.
ADDRESS
APR - 4 1963
Received and Tiled Charles A Mackie
16-62-933404
PLACE OF DEATH
Suffolk
FORM R-301
filed for burial permit h Board of Health or its Agent. INSTRUCTIONS FOR DICAL CERTIFICATE
RINT OR TYPE ISE OR CAUSES OF DEATH do not enter more than one cause for each (a). (b) and (c)
`Ais does not mean mode of dying, k as heart failure. enis, etc. It means disease, or compli- ons which caused
onditions, if any, ·hich gave rise la bove cause (a). using the under. 'ing cause last.
Conditions contrib- { to death but not ed to the terminal use condition given
6 2 776 135
(Print or Type Name) (Address) 3.00rLongwood .... A.v.@Date.4 ..... 2-6.3 .. 14
M. D.
(Signature)
5 Was disease or injury in any way related to occupation of deceased? If so, specify
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis ?
INTERVAL
BETWEEN
ONSET AND
DEATH
22
Due To
Prematurity
(b)
3 DATE OF
DEATH
April 2 1963
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That .I attended deceased from 63 to April 2 19 63
April 1
19
I last saw himive on ... A pr.il ..... 2.
16.3. death is said to
have occurred on the date stated above, a5.2.1.5 ..... a ... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
RespIRAtóRy
Distress
(City or town and State)
... St
(Was deceased a
U. S. War Veteran,
(if so specify WAR).
The Children's Hospital Med. Ctr.
(County)
Due To (c)
Wanttori
Y 14 1963
A TRUR COPY ATTEST: Charles it Mackie City Registrar
1
6
THROP
MAY 1 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, a, etc. It means ease, or compli- which caused
itions, if any, h gave rise to e cause (a), af the under. cause last. 211 C
nditions contrib- o death but not to the terminal condition given
20.1 81 170 Director i use only CK Ink. Y 14 1963 62-932382
PLACE OF DEATH
SUFFOLK
(County)
BOSTON
(City or Town)
KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
(City or Town making this return) 03820
NIMASSACHUSETTS GENERAL HOSPITAL.
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
Alice Davies Howland(GilbertMIAN - IMPORTANT Alice Howland ) Altrex@; }berxxHowlandxxxxxxxxdeceased a (If deceased is a married, widowed or divorced woman, give also maiden name.)
U. S. War Veteran, (if so specify WAR) ....
33 Bellvoew Avenue
St
Winthrop, 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.
3 days. In place of residencef.Z .. years. ....... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
April
2
1963
(Month)
(D)ay)
(Year)
IHET
March 29
19
wel last saw if. .. alive on
April
2
19 63
death is said to
have occurred on the date stated above, at 10 :. 352 .n.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH
12
? HRS
AGE ... 82years ..... 3.
.Months.
7 Days
If under 24 hours
.. Hours .......
Minutes
Due To
ACUTE MYOCARDIAL INFARCTION
(b)
(c)
DISEASE"
OTHER
SIGNIFICANT
CONDITIONS
DISEASE
HYPERTENSIVE HEART
? YRS
.16 BIRTIIPLACE (City)
(State or country)
Massachusetts
Was autopsy performed?
.....
Yes
What test confirmed diagnosis ?
...... Autopsy.
5 Was disease or injury in any way related to occupation of deceased? Ií so, specify .....
(Signature)
M. D.
Chartest:"Cho(pmiPor Type Name)
(Address)Ana's"Dir., Muss. Gen"1. Hosp. .. Date.Apr. 2 1963
Winthrop Cemetery Winthrop, Mass. 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL April 5 1963 ... 19 ....
7 NAME OF
FUNERAL DIRECTOR
alfred To Mark
ADDRESS ........
174 Winthrop St. Winthrop,
APR 9 1903 19 ...........
Received apy
Charles it Mackie
(Registrar)
A TRUE COPY ATTEST:
8 SEX
9 COLOR
white
(write the word) MARRIED widowed WIDOWED DIVORCED UNKNOWN
female
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE
George Howland
(Husband's name in full)
13 Usual
housewife
Occupation :
L DAYS
(Kind of work done during most working life)
14 Industry
or Business:
own home
2 YRS
15 Social Security No .....
015-16-9440-E
Chelsea
17 NAME OF
FATIIER
Samuel Barry Gilbert
PARENTS
18 BIRTHPLACE OF FATHER (City). (State or country) England
19 MAIDEN NAME
OF MOTHER
Mary Ann Fraser
20 BIRTHPLACE OF MOTHER (City) .. (State or country) Nova Scotia
21 Informant
Mrs. Max LeRoy Rorick
(Address)
33 Bellevue Ave. Winthrop
TEREBY CERTIFY that a satisfactory standard certificate of death ME hed with me BEFORE the burial or transit pesegit was issued: Jacqueline Dorate (Signature of Agent of Board of Health or other)
1684 4 4/5/63
(Official Designation)
(Date of I ue of Permit)
.
to
FORTIF April
Je attpided deceasede; fsom
19
(a)
CARDIC RUPTURE
Due To
ARTERIOSCLEROTIC HEART
10 SINGLE
2 FULL NAME
1
Registered No.
A TRUE COPY ATTEST: Charles it mackie City Registrar
MAY 1 41963 AM
1
FORM R-301
ed for burial permit Board of Health or its Agent. NSTRUCTIONS FOR CAL CERTIFICATE
NT OR TYPE E OR CAUSES F DEATH o not enter ore than one use for each ), (b) and (c)
does not mean mode of dying, as heart failure, ia, etc. It means sease, or compli- which caused
ditions, if any, ch gave rise to De cause (a), ing the under. ' cause last. 711 onditions contrib- to death but not ' to the terminal condition given .
330 20
al Director No use only I.CK Ink. MY 14 1963 62-932382
PLACE OF DEATH
SUFFOLK
(County)
1
BOSTON
(City or Town)
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. Į 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.)
9 Eliot Street
Winthrop, Mass.
S
Says. In place of residence years months days. 3
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
MARRIED
WIDOWED MARRIED
DIVORCEE
UNKNOWN
11 If married, widowed, or divorced HUSBAND of
EDITH GRACE
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12 52
... Years.
4.
23
Days
If under 24 hours
Hours ........
Minutes
13 Usual
Occupation:
MACHINIST
14 Industry or Business :..
PORTSMOUTH NAVY YARD
15 Social Security No ...
029-05-6333
16 BIRTHPLACE (City)
(State or country)
SOMERVILLE
MASS
17 NAME OF
FATHER
JOHN A REYNOLDS
18 BIRTHPLACE OF
FATHER (City)
STONHAM
(State or country)
MASS
19 MAIDEN NAME
OF MOTHER
ANNIE G CRONIN
20 BIRTIIPLACE OF
MOTHER (City)
EAST ORANGE
(State or country)
NEW JERSEY
EDITH REYNOLDS (WIFE)
21 Informant ( Address) G ELLIOT ST. WINTHROP MASS
I HEREBY CERTIFY that a satisfactory standard certificate of death wes fled with me BEFORE the burial or transit permit was issued: Raymond Rugeram/ (Signature of Agent of Board of Health or other)
16033 11/4/13
(Date of Tosue of Permit)
T
A TRUE COPY ATTEST:
PARENTS
ST PATRICK'S STONEHAM
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
FRANCIS H, BROWN
ADDRESS 34 BOW ST SOMERVILLE
Keceixed and filed
APR &1 1963
.... .................... .... .... Charles it Mackie
...........
2
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That wenttended deceased from March "22 19. 63 ... , to ....... April 2 19 63
wel last saw H ...... alive on April 2 163 .. , death is said to
have occurred on the date stated above, at
12: 18pm.
INTEIIVAL BETWEEN ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE Subrachnoid Hemorrhage
Due To Aneurysm of Anterior (Communicating Artery
Yrs
Due To (c)
OTHER SIGNIFICANTHypertensive Heart CONDITIONS Disease
Yrs
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) Ass't .. Dir., Mass .. Gan.I .. Hosp ....... Date.Apr ....... 2 ..... 163
6 Place of Burial or Cremation APRIL 5 .19.63
....
(City or Town making this return)
03784
NOMASSACHUSETTS GENERAL HOSPITAL
John L Reynolds
(Was deceased a
U. S. War Veteran,
(if so specify WAR) ...
NONE
(a)
Residence. No ..
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death .... years ......... months
3 DATE OF
DEATH
April
(write the word)
..... (Registrar)| (Official Designation)
( Kind of work done during most working life)
A TRUE COPY ATTEST: Charles it. Mackie City Registrar
i ?
6
MAY 1 41963 AM
1
FORM R-301
led for burial permit Board of Health or its Agent. INSTRUCTIONS FOR ICAL CERTIFICATE
INT OR TYPE SE OR CAUSES OF DEATH do not enter more than one suse for each (a), (b) and (e)
is does not mean mode of dying, as heart failure. nia, etc. It means disease, or compli- s which caused
nditions, if any, ich gave rise to ove cause (a), lling the under. ing cause last.
Conditions contrib- · to death but nat 'd to the terminal se condition given ·).
19.9 07 /
IY 14 1963
PLACE OF DEATH
Suffolk
......
...... (County)
Boston
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
((If death occurred in a hospital or institution,
SK( 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.)
St
Winthrop, Mass.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
April
4
1963
(Month)
(Day)
VA
(Year)
4IHERENY CERTIFY , That Vattended deceased
Mar ...... 16
19 ..
63 ... ..... Apr .... 4.
19
63
from
XXXXXXXXXXXX ...... , death isaid to
have occurred on the date stated above, at .. 4:30A. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Colitis
Due To
Fatty nutritional ..... cirrhosis
yY's.
Due To
(c)
Megaloblastic anemia
unik
OTHER
SIGNIFICANT
CONDITIONS
Pneumonia
wka.
Was autopsy performed ?
Yes
What test confirined diagnosis ?
Autopsy.
5 Was disease or ygury in any way related to occupation of deceased ? If so, specify 2. Huile_
(Address)
(Print or Type Name)
VAH, Boston, Mass.
DateApr ..... 4 ...
........ 63
6
Winthrop Cem., Winthrop,
Mass.
l'lace of llurial or Cremation
(City or Town)
DATE OF BURIAL
April
6
63
FUNERAL DIRECTOR
Kirby Funeral Home
ADDRESS 210 Winthrop St., Winthrop, Mass
Koupived) and filed
APR 9 1963
Charles it. Mackie
.......
(Registrar)|| (Official Designation)
(Date of Issue of Permit)
TVIV
A TRUE COPY ATTEST:
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
11 1f married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
BruceNelson
(Husband's name in full)
12
AGE ..
53.Years .... 3
Months.
25 Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :.
Housewife
(Kind of work done during most of tworking life)
14 Industry
or Business :.
15 Social Security No ...
525.28.4310
16 BIRTHPLACE (City)
(State or country)
Colorado
17 NAME OF
FATHER
Hamer H. Jones
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Miss.
Rich Hill
19 MAIDEN NAME
OF MOTHER
Elta Howe
20 BIRTHPLACE OF
MOTHER (City)
Nacon
(State or country)
Miss
21 Informant
V. A. Hospital Records, 150.S.
(Address)
Huntington Ave. , Boston, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the bugiel or transit permit was issued: Raymond Rogersand (Signature of Agent of Board of Health of other) #1816057 4/5/63
₱-62-933404
X
1
x Veterans Administration Hospital
(City or Town making this return)
Registered No.
033813
Elta J. Nelson (Maiden name: Jones)
(Was deceased a
U. S. War Veteran, WIFII
if so specify WAR) ...
(a) Residence. No.
46
Moore
(Usual place of abode)
Length of stay: In place of death years monthly days. In place of residence 17 years.
.months ......
.. days.
PERSONAL AND STATISTICAL PARTICULARS
INTERVAL
BETWEEN
ONSET AND
DEATH
unik.
(b)
(Signature
M. D.
S. Miller
7 NAME OF
Agular
A TRUE COPY ATTEST: Charles it Mackie City Registrar
MAY 1 41933 AM
X
PLACE OF DEATH
Essex (County )
1
Gloucester
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Gloucester
(City or Town making this return)
Hillcrest Nursing Home No
S (If death occurred in a hospital or institution,
.St. { give its NAME instead of street and number)
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
31 Villa Avenue
st Winthrop, Mass.
(a)
Residence. No
( Usual place of abode)
Length of stay: In place of death .......... years .......... months.
$7
days. In place of residence
45
.... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
6,
1963
DEATH
( Month )
(Day)
(Year)
from
4 I HEREBY CERTIFY, Aug. 15 62
19
That I attended deceased
April 6,
63
er
I last saw
.alive on
April 1,
1963
death is said to
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ..
Harry Graff
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
5 yrs . AGE Years
12
91
6
Months.
28
.. Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Housewife
( Kind of work done during most of working life)
14 Industry
or Business :
Home
15 Social Security No.
New York
none
16 BIRTHPLACE (City)
(State or country )
N.Y.
17 NAME
Edward G. Kennedy
FATHER
18 BIRTHPLACE OF
St. John
FATHER (City)
(State or country )
N.B.
19 MAIDEN NAMEMargaret Jane Greene OF MOTHER
20 BIRTHPLACE OF
New York
( Address )
Gloucester, Mass
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