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