USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 25
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OF TOWN
OFFICE O
7 12.1
10.
NIK
CLERK :N
4
(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.
WI
6.5
HR
(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.
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- JUL [1 11963 AMtant, 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 I 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
GUT
OF - TO21 ....
(City or Town making this return)
Registered No.
05222
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME
Baby Girl .Başch
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
(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 ....... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Single
11 1f married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
HOURS. Years.
Months ...........
Days
If under 24 hours
Hours
20 Iinutes
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :.
15 Social Security No.
MONTHS16 BIRTHPLACE (City)
Boston
(State or country)
17 NAME OF
FATHER
C.N.B.L.
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
C.N.B.L.
19 MAIDEN NAME
OF MOTHER
Ann P. Basch
Winthrop,
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Mass,
21 Informant
Ann P. Basch
(Address)
210 Shore Drive, Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Richard Forman QW. (Signature of Agent of Board of Health or other)
16585
5-15-63
(Official Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
1963
(Day)
(Year)
4 I HEREBY
May 10,
63
19
RTIFY
That Heattended deceased from
May 10,"
63
veI last saw heralive
May .... 10,
1963, death is said to
have occurred on the date stated above, at ...... 2 :102 ... m.
DEATH WAS CAUSED BY :. IMMEDIATE CAUSE
(a) .PREMATURITY.
I I/3
Due To (b)
Due To (c)
PULMONARY ANECTASIS
OTHER
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)
M. D.
Charles L. Clay, M.D." (Print or Type Name) (Address) Ass'ti Dinvy Meser Gen'h. Hep .... .DatMay10, 1963
Gethsemane Cemetery Boston, Mass.
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
May
15.
19
63
7 NAME OF
Eastman Funeral Service Inc.
FUNERAL DIRECTOR
ADDRESS
896 Beacon St., Boston, Mass.
Received and filed
MAY 1 7 1963
19
Charles it Mackie
(Registrar )|
.......
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
210 Shore Drive
St
Winthrop,
Mass ..
DEATH
DECLINED BY MEDICAL EXAMINER
R-301
urial permit f Health ;ent. ONS
IFICATE
TYPE AUSES TH ter one each nd (c) ot mean dying, failure, It means compli- caused
/ any, rise to (a). under- last.
contrib- but not terminal riven
16 35 1963 ctent only k. 2382
May .... 10,
(Month)
to ...
INTERVAL
BETWEEN
ONSET AND
DEATH
PARENTS
X
NOMASSACHUSETTS.GENERAL .. HOSPITAL
A TRUE COPY ATTEST:
Williamh Kane. City, Registrar
TO:
KLERK
6
YROR
JUL 251963 PM
1
301
I
BOSTON
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
122 OUT - OF - TATOTT To be filed for burial permit with Board of Health or its Agent.
Registered No.
05236
[(If death occurred in a hospital or institution,
............... St. Į give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Ruby H. Walton
(Berry)
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
61 Washington Avenue
(a) Residence. No.
(Usual place of abode)
1
months.
26
days.
In place of residence.
40 years
.months.
......
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 CITIZEN
OF U.S.
YES
NO
II SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
4 I HEREBY CERTIFY,
Mar.c.h ..... 18 .. ,
.19 ... 6.3. ... May 14, ....
.. 1.96.3
That weattended deceased from
le last
h.a.Blive
May 14,
19 .... Q .. 3, death is said to
have occurred on the date stated above, at
5:27P ... m.
INTERVAL BETWEEN ONSET ANO DEATH
12 DATE OF BIRTH
Dec. 11 1669
AGE
73
Years ...
5
.Months.
3
.. Days
If under 24 hours
....
... Hours .............. Minutes
Due To
OEsophageal and Gastric Varites
Due To
"Nutritional Cirrhosis
OTHER
SIGNIFICANCoronary Heart Disease
CONDITIONS
years
16 Social Security No.
018-16-4495
rest Medway
17 BIRTHPLACE (City)
(State or country)
Massachusetts
18 NAME OF
FATHER
Charles Berry
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Unable to obtain
(Signed)
M. D.
Cheries L. Cl., M. D.
(Print or Type Name)
(Address)
Ass's, Dir., Mose Gon'%. Hosp. Date.
5/15/ .19.63 19
6 Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Liay
17
19 ...
53
7 NAME OF
FUNERAL
DIRECTOR
Howard S Reynolds
ADDRESS Winthrop, L'ass
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit @ermit was Issued:
Carolyn Ware
Received pod Bied
1 ... 19 Charles it Mackie
(Signature of Agent of Board of Health or other)
16598
5-16-65
(Official Designation)
(Date of Issue of Permit)
T
A TRUE COPY ATTEST:
3
-
any, se to (a), nder- last. contrib- but not erminal given
137. requires print or ause or cath on ates, and Acts of s Physi- t or type ignature.
1963 ten aly k.
PLACE OF DEATH
SUFFOLK
(County)
No.
Massachusetts General Hospital BAKER MEMORIAL
...........
[(Was deceased a U. S. War Veteran,
{if so specify WAR)
Xx
Winthrop, Massachusetts
(If nonresident, give city or town and State)
3 DATE OFMay 14,
DEATH ..
1963
(Month)
(Day)
(Year)
lla If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Frank E nalton
(Husband's name in full)
5 days3
14 Usual
Occupation :
Clerk
(Kind of work done during most of working life)
years 15 Industry
Cemetery Office
or Business :
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
@c.@low
PARENTS
20 MAIDEN NAME
OF MOTHER
Lillie Mac Intosh
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Unable to obtain:
22
Marguerite Walton
Informant
(Address)
Washington avC. winthrop, la
MAY 21 1963
(Registrar)
NS
FICATE
EATH er one ach d (c) mean dying, failure, means compli- caused
Length of stay: In place of death.
years ..
19
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)Gastrointestinal Hemorrhage
years
A TRUE COPY ATTEST:
--
Williamal Kane. City Registrar
1
X
PLACE OF DEATH
Suffolk (County) Boston
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
OUT OF TOWN
(City or Town making this return)
STANDARD
CERTIFICATE OF DEATH
Registered No.
05382
)
[(If death occurred in a hospital or institution,
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.)
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
No
(a) Residence. No.
(Usual place of abode)
293 BowDown St. Winthrop,
Massachusetts
(City or town and State)
Length of stay: In place of death years months/ 4 days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
Female White
10 SINGLE
MARRIED
WIDOWED
DIVORCEDMARRIELL
11 If married, widowed, or divorced
HUSBAND of ..
Rocc"
DiNODIA
(Husband's name In full)
12
AGE/
76
Years
Months.
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Housework
Occupation :
(Kind of work done during most of iworking life)
14 Industry
or Business :
OWN Home
15 Social Security No CNBI
16 BIRTHPLACE (City).
(State or country )
BOSTON, MASS.
17 NAME OF
FATHER
DANIEL RING
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston
mass.
19 MAIDEN NAME
OF MOTHER
Catherine Flaherty
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
MASS.
Boston
21 Informant
Robert Di Nubla
243 Bowdoin St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certifcate of death filed with me BEFORE the burial or transit permit was issued: 7.P. Graça B 01280 (Signature of Agent of Board of Health or other) may 21,1963
Received and
MAY 23 1963' Charles it mackie
......
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
May 6
19 63
, to May
20
1963
I last saw heralive on
May
20
1963, death is said to
have occurred on the date stated above, at
4:10 pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Pneumonia LabAR
Due To
Intestinal Obstruction
(b)
Due To
Diverticulitis, sigmoid Colon
(c)
OTHER
SIGNIFICANT
CONDITIONS
Pulmonary Tuberculosis
20 yrs
Was autopsy performed ?
No
What test confirmed diagnosis ?
operation-5-7-63
5 Was disease or injury in any way related to occupation of deceased ? No If so, specify
(Signature)
Causale 7 minton. 8
M. D.
Russell F. Minton, JI
(Address)
(Print or Type Name)
Beth Israel Hosp. Date 5-20 1963
New CALVARY
Boston
Place of Burial or Cremayon
MAY 22
,63
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Frederick J. MAGRATH
EAST BOSTON
ADDRESS
PARENTS
A TRUE COPY ATTEST:
(Registrar)|| (Official Designation)
(Date of IQue of Permit)
Xi €
-
urial permit of Health gent. ONS
IFICATE
TYPE AUSES TH ter one each nd (c) of mean dying, failure, It means compli- caused
y any, rise to (a). under- last.
contrib- but not terminal on given
54
1963
Lo4
3 DATE OF
DEATH
(Month)
MAY
20
1963
(write the word)
(Give maiden name of wife in full)
(or) WIFE of
INTERVAL
BETWEEN
ONSET AND
DEATH
10 days
14 days
7
(City or Town)
123
BETH ISRAEL HOSPITAL No MARY DiNUBLA
R-301
A TRUE COPY ATTEST:
Williamf. Kane. City, Registrar
,
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
124
OUT - OF -TOWN OWN
(City or Town making this return)
Registered No.
05261
[(If death occurred in a hospital or institution,
No
St. { give its NAME instead of StEss! Anf PHYSICIAN - IMP number)
2 FULL NAME
M. Augustus L. Norris
(If deceased is a married, widowed or divorced woman, give also inaiden name.)
(a) Residence. No.
37 Bay View Ave.
St.
Winthrop, Mass.
(City or town and State)
Length of stay: In place of death .......... years .......... months.
O days. In place of residence6 ..... years ....... months ......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWEMMarried
DIVORCED
UNKNOWN
11 lf married,
Ruth Gilbert
HUSBAND of
(Give maiden name of wife in fuil)
(or) WIFE of.
(Husband's name in fuli)
12
AGE 57 ... Years.
Months ....
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Welder
(Kind of work done during most of iworking life)
14 Industry
or Business :.
U ...... S ...... Arsenal
15 Social Security No .. 012-14-4423
16 BIRTHPLACE (City). Winthrop (State or country) Mass
17 NAME OF FATHER Augustus W. Norris
18 BIRTHPLACE OF
FATHER (City).
Halifax
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Ellen G. Lane
20 BIRTHPLACE OF
MOTHER (Clty)
East Boston
Mass
(State or country)
21 Informant
Ruth Norris
(Addres
37 Bay View Ave.
I HEREBY CERTIFY that a satisfactory standard certifcate of death was Aled with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
67500
Anna 1/453
(Official Designation) ( Date of Issue of Fermit)
THEV 1
S
CATE
PE JSES 1
r ne ch (e) mean dying, allure, means ampli- caused
ERy. e la (a). der- last . ontrib. ut sat rminal given
Was autopsy performed?
Yes.
What test confirmed diagnosis ?
AUTOPSY.
S Was disease or injury in any way related to occupation of deceased? NO If so, specify - (Signature) C.K. GORMAN. M. D. 51stmay 1963 PARENTS
(Print or Type Name)
(Address N.E. DEACONESS 800? Date
6 Winthrop Cemetery Winthrop
Place of Buria! or Cremation
(City or Town)
DATE OF BURIAL June 3,
19 .63
7 NAME OF
FUNERAL DIRECTOR
ArthurJ .0' Maley
.. ...
ADDRESS
Winthrop, Mass
Received and filed
JUN
4 .... 1963
.19
Marcel, Manning
ASSY
A TRUE COPY ATTEST:
May 31, 1963
(Month)
(Day)
(Year)
4I HERENY CERTIFY
May 25,
19
to ..
63
May 31,
19.
63
I last saw h. imlive on
May .... 31,
have occurred on the date stated above, at
1:30 .... P.n.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
CORONARY ARTERY OCCLUSION.
19.63
death is said to
INTERVAL
BETWEEN
ONSET AND
DEATH
I WR.
(a)
Due To ARTERIOSCLEROTIC HEART DIREASE (b)
2mo
1YRS
OTHER
SIGNIFICANT
CONDITIONS
DIABETES MELLITUS.
(c) ......
-
61 170
963
R-301
al permit Health t.
New England Deaconess Hospital
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
No
(Usual place of abode)
(write the word)
3 DATE OF
DEATH
That 1 attended deceased from
(Registrar)|
A TRUE COPY ATTEST:
William& Kasse: City REBRESF
Of=TOW
ERKERK ET? NTHROR NA'S
1.
6
JUL 2/51963 PM
JUL 251963 PM
-302
PLACE OF DEATH
Suffolk (County)
Chelsea (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
125
Chelsea
(City of Town making this return)
Registered No.
3.46
[(If death occurred in a hospital or institution,
....... .. St. ¿ give its NAME instead of street and number)
2 FULL NAME ...
Mary ...... Douglas
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR
(a) Residence. No ...
(Usual place of abode Loring Road
.........
S
Anthrop Hass
(If nonresident, give city of 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
9 COLOR
(write the word)
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Single
Female
White
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.88
Months ..... 7 ... Days
If under 24 hours
Hours ........ Minutes
Arterioselerotie heart
Due To
(b)
disease
1 mo.
Due To
(c)
Arteriosclerosis
OTHER
SIGNIFICANT
CONDITIONS
"Lobar pneumonia
2 wks
Was autopsy performed ?
.no
What test confirmed diagnosis ?
x-ray & clinical
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
CharlesJ.Ferrera
M. D.
(Address)
154 Bennington St. 6/14/63
Fast Boston, Mass.
6
Winthrop, Mass
(City of
DATE OF BURIAL
June ...... 17. 1963
19
7 NAME OF
FUNERAL DIRECTOR Howard .... S.Reynolds
ADDRESS
Winthrop,Mass.
Received and filed
AUG 5 1963
19
(Registrar of City or Town where deceased resided)
21 Informant
Margery ..... Fenton
(Address)
39 Lovejoy Rd., Andover, Mass.
A TRUE COPY
Joseph a. Tyrrell
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
June 16,1963
TUBI .19
1
17 NAME OF FATHER Alexander Douglas
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Scotland
19 MAIDEN NAME
OF MOTHER
Margaret Alexander
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
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 resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
1
(Month)
4 I HEREBY CERTIFY, That I attended deceased from
May 1
1963 ...
to ........... June 14
death is said to
I last saw h .. palive on
June 14
19.6.3
have occurred on the date stated above, 4 p
.111.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL
BETWEEN
ONSET AND
DEATH
(a)
13 Usual
Occupation :
Bookkeeper
(Kind of work done during most working life)
14 Industry
or Business :.
Publishing Co.
15 Social Security No .. 013-07-8487.
16 BIRTHPLACE (City)
(State or country)
Boston, Mass.
PARENTS
3 DATE OF
DEATH
June 14, 1963
(Day)
(Year)
No.Chelsea Memorial Hospital
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
1:
6
HRAD
AUG | 51963 AM
×
R-302
PLACE OF DEATH
Essex Gloucester
(County )
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
126
Gloucester
(City or Town making this return)
Registered No. .
No.
Addison Gilbert Hospital
§ (If death occurred in a hospital or institution, .St. ¿ give its NAME instead of street and number)
2 FULL NAME.
Mabel Sophia Doleman
( If deceased is a married, widowed or divorced woman, give also maiden name.) U. S. War Veteran. if so specify WAR,
126 Court Road
St inthrop
...... S.S.
(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 residence.O.
.. years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June
28
1963
3.
(Day)
(Year)
8 SEX
Female
9 COLOR
White
MARRIED
WIDOWED
Married
4 I HEREBY CERTIFY,
That I attended deceased
from
April 50 June 28
19.
to ...
June 28
63
have occurred on the date stated above, at . .m.
INTERVAL
BETWEEN
ONSET AND
DEATH
(or) WIFE of ..
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years ..
0
MonthsO
.Days
If under 24 hours
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. 10-05-8370B
lockeport, N. S.
16 BIRTHPLACE (City)
(State or country)
Canada"
17 NAME OF George H. hiltz
18 BIRTHPLACE OF
Lockeport, N.S.
FATHER (City)
(State or country )
Canada
19 MAIDEN NAME
OF MOTHERAGE Letilia Crowell
20 BIRTHPLACE OF
MOTHER (City )
(State or country )
Nova scotia
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
July
1,
19
7 NAME OF
FUNERAL DIRECTOR
Arthur J. OMaley
ADDRESS
inthro,
Mass .
Received and filed
JUL 17 1963
.. 19
DATE FILED,
(Registrar of City or Town where death occurren)
.
14/ 03
( Registrar of City or Town where deceased resided )
PARENTS
( Signed )
C. Bruce Brown
( Address )
M. D.
Rockoort, Hass.
Date.
6/23
19
,03
inthrop 6
inthrop, Mass.
21 John Soloman
Informam ( Address+
A TRUE COPY
Fred
ATTEST :
Digrauz
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.)
50M-9-59-926111
Due To (c)
OTHER
Aplastic anemia
1 mo.
SIGNIFICANT
CONDITIONS
NO
Was autopsy performed ?
What test confirmed diagnosis ?Ificar
NO
5 W'as disease or injury in any way related to occupation of deceased ? If so. specify
5 dys
10a If married, widowed. or giyersed Edgar Doleman
HUSBAND of
(Give maiden name of wife in full)
I last saw
er
...... alive on
, ..... , 19 ...
death is said to
4:55P
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Cerebral vascular thrombosis
(a)
Due
Arteriosclerosis
(b)
1
(City or Town)
( Was deceased a
10 SINGLE
( write the word)
(Month)
1963
SPACE FOR ADDITIONAL INFORMATION
THEOR
DATE OF ENTERING MILITARY SERVICE
JUL 1 71963 AH
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-302
Copies of returns of deaths which occurred in your city of town in case the deceased resided in another city of town Due To (c) 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
50M - 10-61.931673
PLACE OF DEATH
Suffolk
(County)
Revere
(City or Town)
No
Harry Clinton Beless
(If deceased is a married, widowed or divorced woman, give also maiden name.)
338 Pleasant
(a) Residence. No ..
(Usual place of abode)
14
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
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
11 If married, widowed denceKendall Farrand HUSBAND of
(or) WIFE of.
(Husband's name in full)
80
1
12
AGE
Years
Months ..
15
.Days
If under 24 hours
Hours .......
Minutes
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
Hospital supplies
or Business :
012-03-1968
15 Social Security No ....
Heegham
16 BIRTHPLACE (City)
(State or country)
Mass.
17 NAME OF
FATHER
John Henry Beless
18 BIRTHPLACE OF
Needham
FATHER (City)
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Mary Lee
20 BIRTHPLACE OF
MOTHER (City)
(State or country )
Mass.
Brookline
Theadore L. Beless
21 Informant
(Address)
338 Pleasant St., Winthrop
A TRUE COPY
ATTEST:
DATE FILED
(Registrar of City of Town where death occurred)
July
2,
1963
T VED
...
Due To (b)
OTHER
SIGNIFICANT
CONDITIONS
No
Was autopsy performed?
Clinical, Pathological
What test confirmed diagnosis ?
no ......
(Signed)
M. I).
(Address)
Winthrop
6/30
63
Date
19
Winthrop Cemetery 6
Winthrop
Place of Burial or Cremation
July
2,
(City or Town)
63
19
7 NAME OF
FUNERAL DIRECTOR
Alfred B. Marsh
174 inthrop St., Winthrop
ADDRESS
Received and filed
JUL 12 1963
19 ..
(Registrar of City or Town where deceased resided)
PARENTS }
127
Revere
(City or Town making this return)
Registered No.
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
(Was deceased a
U. S. War Veteran,
NO
(if so specify WAR,
Winthrop
.. St ...
(If nonresident, give city or town and State)
30
3 DATE OF
DEATH
June
29.
1963
(Month)
(Day)
(Year)
August
19
to.
June
29
I last saw h ...... alive on
9: 15A .
have occurred on the date stated above, at
111.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cancer of Breast
(a)
INTERVAL BETWEEN ONSET AND DEATH
19
63,
death is said to
Y
CERTIFY
"Juflet I meyded deceased (fran
Male
(Give maiden name of wife in full)
Retired salesman
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
Charles Liberman
DATE OF BURIAL
Ocean View Manor
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
1
2 FULL NAME.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE. RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
1
JUL 1 21963 AMI
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
128
(City or Town making this return)
.....
§(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME
Roslyn May Paro (Doane)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
587 Pleasant Street
St
(If nonresident, give city or town and State)
Length of stay: In place of death ...
3
years .......... months.
days. In place of residence 25 years 7 months 0 days.
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