Town of Winthrop : Record of Deaths 1963, Part 42

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 42


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


CLERK


RM R-301


· burial permit of Health Agent. CTIONS R ERTIFICATE


R TYPE CAUSES ATH enter an one or each ) and (c)


not mean of dying, art failure, c. It means or compli- ich caused


s, if any, ve rise to use (a), he under- use last.


ons contrib- ath but not the terminal dition given


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


(City or Town making this return)


210


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


2 FULL NAME


Arthur C Glendenning


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


(a)


Residence. No ..


24 Taylor Street


(Usual place of abode)


Length of stay: In place of death .1.5years. .... months ... days. In place of residence ..... 2years.


... months ....


... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


October


1.7


1.9.63.


(Month)


(Day)


(Year)


4 IHEREBY CERTIFY, That I attended deceased from 19 .. , to .. 19


I last saw h ...... alive on 19 ........ , death is said to


have occurred on the date stated above, at 11:15Pm.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Death presumably que


Due To


(b)


to natural causes.


Due To


(c)


...


on the basis of


generalized arteriosclerosis. SIGNIFICANT CONDITIONS Winthrop Board of Health


Was autopsy performed?


Clearles Liber man mi


What test confirmed diagnosis ?


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


(Signature)


Charles Liberway, M


CHARLES LIBER MAN


(Print or Type Name)


(Address)


WINTHROP MASS Date 16/18/1963


Ba tlett Cemetery, Bartlett, N.H 6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


October 21, 1963


19.


7 NAME OF


FUNERAL DIRECTOR


alfred B. March


ADDRESS


174 Winthrop St. Winthrop,


Received and filed


OCT 18 1963


19


(Registrar)|


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


10 SINGLE


(write the word)


MARRIED Single


WIDOWED'


DIVORCED


UNKNOWN


Male


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


82 Years.


10


12


Days


If under 24 hours


Hours ......


.. Minutes


13 Usual


Occupation


Retired Rail Road Employee


(Kind of work done during most working life)


14 Industry


Maine Centrall Rail Road


or Business


15 Social Security No ..


003-01-3577


16 BIRTHPLACE (City)


(State or country)


New Hampshire


17 NAME OF


FATHER


James B. Glendenning


18 BIRTHPLACE OF


FATHER (City)


Bartlett


(State or country)


New Hampshire


19 MAIDEN NAME


OF MOTHER


Margaret Jameson


20 BIRTHPLACE OF


MOTHER (City).


Bartlett


New Hampshire


(State or country )


21 Informant


Mrs. Joseph Mundy.


( Address)


24 Taylor St. Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death Matas fled with'me BEFORE the burial or transit permit was issued: Caiplo Ce Vizinno (0)


(Signature of Agent of Board of Health or other)


Health offene


Oitalien 18 1963


(Official Designation)


(Date of Issue of Permit)


X


A TRUE COPY ATTEST:


-932382


1


No. 24 Taylor Street


PHYSICIAN - IMPORTANT


) (Was deceased a


U. S. War Veteran,


(if so specify WAR)


N.O ..


St


(If nonresident, give city or town and State)


Registered No.


Bartlett


PARENTS


INTERVAL


BETWEEN


ONSET AND


DEATH


TOW


OrFf


MERK


SPACE FOR ADDITIONAL INFORMATION


0


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


OCT 1 81963 PM


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER.


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :


(1) Attending physicians will certify to 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.


PLACE OF DEATH


Suffolk


CINSI ME


winthrop


(City or Town)


No.


Winthrop Conv :lesent Home


The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


To be filed for burial permit with Board of Health or its Agent.


211


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


2 FULL NAME.


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


142 Pleasant ut


(a) Residence. No.


(Usual place of abode)


1


Length of stay: In place of death.


.. years.


4


35


months ..


.. days. In place of residence.


years


months


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


October


1.0


(Month)


(Day)


(Year)


THEREBY CERTIFY, That I attended deceased from


4


46, 0


October 13


19.63


63


19.


.. , death is said to


have occurred on the date stated above, at


11:00PM


... m.


INTERVAL


BETWEEN


ONSET AND


DEATH


I mo.


12


82


5


5


If under 24 hours


Hours.


Minutes


Due To


(b)


Senility


years


3 Usual


Occupation :


(Kind of work done during most of working life)


14 Industry


or Business :


CITI Home


15 Social Security No.


16 BIRTHPLACE (City.),


(State or country)


17 NAME OF


FATHER


"ilron


18 BIRTHPLACE OF


FATHER (City)


(State or country)


udler Cha


19 MAIDEN NAME


OF MOTHER


.mail f rrel


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


21 Luth Crore


Informant


(Address)_1


I HEREBY CERTIFY that a satisfactory standard certificate of death way filed with me BEFOKE the burial or transit permit was issued: Ralph 6. Lerianne () (Signature 'of Agent of Board of Health or other) Health Offer October 21,1963


(Official Designator)


(Date of Issue of Permit)


TX


CTIONS R ERTIFICATE


iving F DEATH enter an one or each ) and (c)


s not mean of dying, art failure, c. It means or compli- ich caused


s, if any, ve rise to use (a), he under- use last.


ons contrib- ath but not the terminal dition given


chapter 137, 54. requires to print or cause or death on ficates, and 8, Acts of ires Physi- int or type r signature.


6


Place of Burial or Cremation


DATE OF BURIAL


(City or Town)


Ut.


1920


7 NAME OF


FUNERAL DIRECTOR .410'


ADDRESS ......


Received and filed


OCT 2 1 1963


19


(Registrar)


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWED)


. ido: Cel


10a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


Robert


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


AGE


Years


Months.


,Days


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


NO


What test confirmed diagnosis ?


-


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


If so, specify


NO


(Signed)


H.B. Greenfield


M. D.


(PRINT OR TYPE SIGNATURE)


(Address)


447 Propina Date Oct19 19 63


.intro


PARENTS


Registered No.


PHYSICIAN - IMPORTANT [(Was deceased a U. S. War Veteran, [if so specify WAR)


Eunice I ("'ilson) Veiteli


St.


(If nonresident, give city or town and State)


(Give maiden name of wife in full)


Velten


I last saw He ralive on


oct


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Uremia


(a


(County)


R-301A 1


59-925686


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


5


ERK


6


THROR


RULES OF PRACTICE OCT 2 11963 FM


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa . tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.


X PLACE OF DEATH 1


SUFFOLK


(County)


MINTHAOP


(City or Town)


6 Central St. No.


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


STANDARD CERTIFICATE OF DEATH


Registered No.


212


[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME ..


Charles W. King


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


6 Central St.


(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


October 23, 1963


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY , That I attended deceased from


19


to ..


19


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


19 ........ , death is said to


have occurred on the date stated above, at


5:55 a.m.


INTERVAL BETWEEN ONSET AND DEATH


Due To (b)


Due To (c)


OTHER


Deceased was patient at Vet, Adm.


SIGNIFICANTHospital ..... Boston .. Mass ..... from


CONDITIONS8 /27/63 to 10/14763.


·


Tiamosi!


Was autopsy performed? neumonia with Effusion.


What test confirmed diagnosis ?


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


(Signature)


M. D. John/F. Collins, M.D.


Winthrop


(Print or Type NamBoard of


.... Health


(Address) 7 Bennington St. Date Oct. Revere, Hars.


6 "Tinhroa Cemetery, Tintinan


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


Oct. 26,


19 63


7 NAME OF


FUNERAL DIRECTOR


Ernest I. Condinho


ADDRESS


147 Firon St., MMmm


Received and filed 10- 24 - 1963


A TRUE COPY ATTEST:


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


Lale


Thite


10 SINGLE


MARRIED


WIDOWED


(write the word)


DIVORCEDDivorced


UNKNOWN


II If married, widowed, or divorced


HUSBAND of


nna Marschello


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


12


45


AGE


Years.


Months.


.. Days


If under 24 hours


Hours .......


Minutes


13 Usual


Occupation


Clerk


(Kind of work done during most of working life)


14 Industry


or Business


Fruit & Produce


15 Social Security No. 015-05-9135


16 BIRTHPLACE (City) act boston


(State or country )


ass.


17 NAME OF


FATHER


James King


18 BIRTHPLACE OF


FATHER (City) ..


(State or country )


Nova Scotia


19 MAIDEN NAME


OF MOTHER


Amie Moleun


20 BIRTHPLACE OF


MOTHER (City)


(State or country )


Canada


21 Informant


Helen .ius


(Address)


6 Contr 1 St.,


winthrop


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


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


( Registrar)// (Official Designation) (Date of Issue of Permit)


X


M R-301


burial permit d of Health Agent. TIONS R ERTIFICATE


R TYPE CAUSES ATH enter an one r each ) and (c)


not mean of dying, art failure, .. It means or compli- ich caused


, if any, e rise to use (a), e under- use last.


ons contrib- ath but not" he terminal ition given


at 5:55 a.m. by Charles Liberman, M.P. Certificate 5 signed by John F. Collins, I&D.


Pronounced dead October 23,1963


(City or Town making this return)


(Was deceased a


U. S. War Veteran,


(if so specify WAR).


St


Winthrop Hass.


(City or town and State)


PARENTS


33,19206321


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Presumably dreto NaturalCauses


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE. Jex 3. 1944


DATE OF DISCHARGE. Monpihen 30 1045 ...


RANK, RATING


Coxsw in USER


ORGANIZATION AND OUTFIT


SERVICE NUMBER 8035374


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 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.


¥


REVERS 11-9-63


Suffolk (County)


LENSE


Winthrop (City or l'own)


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


To be filed for burial permit with Board of Health or its Agent.


213


§(If death occurred in a hospital or institution, Winthrop Community Hospitals S NAME


PHYSICIAN - IMPORTANT


Michelina Sala


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


[if so specify WAR)


(a) Residence. 12 Struth avenue (Usual place of abode)


ST.


- Revere mass,


(If nonresident, give city )or town and State)


...... months ..


days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


7%


9 COLOR


W


10 SINGLE


(write the word)


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


October 24, 19 6 9 October 25


63


19.


I last saw he Zalive on


Octatev 56, 1963 death is said to


have occurred on the date stated above, at 3,300 m.


INTERVAL


BETWEEN


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a) [acute Myocardial en foret


ONSET AND


DEATH


3 hrs


10a If married, widowed, or divorced


HUSBAND of


Fiorentina Sala


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE 66 Years


.. Months.


.. Day's


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Nousenige


(Kind of work done during most of working life)


14 Industry


or Business :


15 Social Security No.


16 BIRTHPLACE (City) (State or country)


Italy


17 NAME OF


FATHER


Michele Blasi


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


19 MAIDEN NAME OF MOTHER Francesca Viglione


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


Peresa Bas, LIME


(daughter)


21


Informant


(Address)


72 Jours De


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Preph E fiveanne (Bs)


(Signature of Agent of Board of Health or other)


Health Fluer


(Catalov :25, 1963


(Official Designation)


(Date of Issue of Permit)


X


-301A 1


IONS


TIFICATE


ing DEATH nter n one each and (c)


not mean of dying, t failure, It means or compli- h caused


if any, rise to e (a), under- e last.


-


Due


Hypertension


(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


Rose F. JANNINI M. D.


400 pleas (PRINT OR TYPE SIGNATURES


(Address Vanitas Mass Dat COCTEL 201963


Woodlawn Gemeten Cremeit 6


l'lace of Burial or Cremation


(City of Town)


1)ATE OF BURI Cxulu 28 19 ... 665-3


7 NAME OF tannini hypementa ADDRESS :224 Marth Stuit Boston, mans


Received and filed OGT 25-1963 19


(Registrar)


PARENTS


arteriosclerosis


(b) ...


October 25


1963


MARRIED


WIDOWED


or DIVORCED


Widowed


Length of stay : In place of death. ............ years. .. months RAJdy's. In place of residence 21 years


[(Was deceased a U. S. War Veteran,


Registered No.


2 FULL NAME


PLACE OF DEATH No.


pter 137. , requires o print or cause or death on cates, and Acts of es Physi- at or type signature.


s contrib- h but not e terminal tion given


.925686


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice : (1) Attending physicians will certify to 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.


REDE YED


OF TOW


OFFICE ()


10.


MINI


LERK


8


*


1


6


5


10


NTHROF


OCT 2 51963 PM


PLACE OF DEATH


SUFFOLK (County) WINTHROP (City or Town)


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD


CERTIFICATE OF DEATH


Registered No.


214


BAY VIEW NURSING HOME 26 STOREUS No.


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


PHYSICIAN - IMPORTANT


[(Was deceased a


U. S. War Veteran,


{if so specify WAR)


NO


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


Length of stay: In place of death


3


.... years.


months ............


.days. In place of residence ...


40 years.


.months.


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


October


26.


1.9.6.3


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


1-27-53


19


to ..


10-26.


19 ... 6.3


19 ..


.. 6.3 death is said to


(Give maiden name of wife in full)


(or) WIFE of


DAVID VANTYNE


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


10yrs AGE 91 Years ..


Months.


Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


SECRETARY (RETIRED


(Kind of work done during most of working life)


12 YF 4 Industry


FARM EQUIPMENT


or Business :


15 Social Security No. 030-03-1741


HAVERHILL


OTHER


SIGNIFICANT


CONDITIONS


.pernicious ..... anemia


10yrs


Was autopsy performed ?


no


What test confirmed diagnosis? clinical &lab


5 Was disease injury in any way related to occupation of deceased ? no. If so, specify ) ...


(Signed)


M. D. M. Traunstein. . Jr ..... M.D. (PRINT OR TYPE SIGNATURE) (Address) Winthrop., Mas.s ......... Date .. 1.0 ...... 28.


.. 19.6.3.


WINTHROP


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


OCT 29


43


7 NAME OF


FUNERAL DIRECTOR


MAURICE W KIRBY


ADDRESS WINTHROP


OCT 28 1963


19


(Registrar)


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


NH.


19 MAIDEN NAME


OF MOTHER


THERESA BOULE


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


P 1.


21 MAS DOROTHY KIRBY


Informant


(Address)


TAMPH / FLA


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph 6, Sirianni (Signature of Agent of Board of Health or other)


Health Officer


act. 28, 1963


(Official Designation)


(1)ate of Issue of Permit)


T X


-301A 1


TIONS


RTIFICATE


ing DEATH enter n one : each and (c)


not mean of dying, rt failure, It means or compli- h caused C.


if any, rise to se (a), under- se last.


is contrib- h but not e terminal tion given


apter 137. , requires o print or cause or death on cates, and Acts of es Physi- nt or type signature.


-925686


2 FULL NAME


GRACE (HARRIMAN) VAN TYNE


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


26 -STURGES ST 49 Beal St.


8 SEX


FEMALE


9 COLOR


WHITE


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED WIDOWED


10a If married, widowed, or divorced HUSBAND of


I last saw h.


e Five on


Oct.


24


6:15a.m.


have occurred on the date stated above, at


INTERVAL


BETWEEN


ONSET AND


DEATH


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


Arteriosclerotic & hyper-


tensive heart disease


(a)


Due To


(b)


Generalized arteriosclersi


Due To (c)


16 BIRTHPLACE (City)


(State or country)


MASS


17 NAME OF


FATHER


HIRAM HARRIMAN


CONWAY


PROVIDENCE


WINTHROP


6


Received and filed


St. WINTHROP


(If nonresident, give city or town and State)


To be filed for burial permit with Board of Health or its Agent.


)


-


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :




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