USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 47
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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'M 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.
1
Statement of Cause of Death .- Physicians: see explanatory instructions. on face side of standard certificate of death.
6
THROP.
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 bodypat tion bad been given up or changed, or if the deceased bad 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.
91963 EM
RM R-301
1
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
Registered No.
239
[(If death occurred in a hospital or institution, AmosCrooks Win. Com ...... Hosp .St. [ give its NAME instead of street and number) No .....
illard Amos W, Crooks
PHYSICIAN - IMPORTANT
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
34 Thornton Park
(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 :........ years .......
... months ... ] .. 2days. In place of residence5.5.years ..
...... months. .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
Married
MARRIED
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
Grace Caroline Ford
HUSBAND of
(or) WIFE of.
(Husband's name in full)
12
AGEZ.3 ... Years. 9.
Months.
6
Days
If under 24 hours
Hours ........
Minutes
Due To
(b) Carcinoma of Prostate
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
None
Was autopsy performed ?
None
What test confirmed diagnosis? Clin. & Lab.
5 Was disease or injury in any way related to occupation of deceased? . No If so, specify
(Signature)
Mourir Trause S/ Ein, NC M. D.
Maurice Traunstein, Jr., M.D.
(Print or Type Name)
(Address) 73 .... Bartlett .... Rd. ........... Dat Nov. 20 19 63 Winthrop, Mass.
6 Woodlawn Creamatory
Everett, Mass.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
November 22 ,1963
.19.
7 NAME OF
FUNERAL DIRECTOR
alfred B. March
ADDRESS
174 Winthrop St. Winthrop,
Received and filed
NOV 2.2 1963
19
(Registrar)
A TRUE COPY ATTEST:
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Philedelphia
19 MAIDEN NAME
OF MOTHER
Helen Willard
20 BIRTHPLACE OF
MOTHER (City)
Malone
(State or country)
New York
21 Informant
Mrs ...... Amos .... W. Crooks ...
( Address)
34 Thornton Park, Winthrop
Mas HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Laspl & Serianni (2)
(Signature of Agent of Board of Health or other)
Health Officer
nov. 22. 1963
(Official Designation)
(Date of Issue of Permit)
J V. VB
3 DATE OF
DEATH
November
20
19.6.3.
(Month) (Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Nov ......
6
150
to .. Nov ....... 20
63
I last saw Imalive on .. N.o.v ....... ].9.
19 .... 6.3death is said to
have occurred on the date stated above, at .. 6:10.2 .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Generalized carcinbmatosis
INTERVAL BETWEEN ONSET AND DEATH
1 yr.
33 yrs.
Occupation :
Engineer
(Kind of work done during most working life)
14 Industry
or Business :
Air Conditioning Co.
15 Social Security No.
012-01-4537
16 BIRTHPLACE (City)
Malone
(State or country )
New York
17 NAME OF
FATHER
Warren Crooks
-932382
r burial permit d of Health Agent. CTIONS
OR ERTIFICATE
R TYPE CAUSES CATH enter an one or each ) and (c)
s not mean of dying, cart 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
Withrop
(City or Town making this return)
St
(If nonresident, give city or town and State)
(Give maiden name of wife in full)
13 Usual
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RECEIVED
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
OFFI
2
CLERK
W
5
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance following rules of practice :
NOV 2 21963 AM
(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.
71 12 1 ...
1
PLACE OF DEATH
1 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)
23 THORNTON PARA No.
S(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).
NC
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of deat
36 years 16 months.
days. In place of residence Ste years
months ...... ... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
November
29
1963
DEATH
(Month)
(Day)
(Year)
4
I HEREBY CERTIFY,
That I attended deceased from
Nov 27 19 63 to Nov 29
to ..
63
I last saw h ...... alive on
Nov
27
19 ..
6 5 death is said to
have occurred on the date stated above, at
7.10 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic Heart Disease
INTERVAL BETWEEN ONSET AND DEATH 1 yr
Due To Arteriosclerosis
(b)
3yrs
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
None
Was autopsy performed?
No
What test confirmed diagnosis ?
Clinical Findings
5 Was disease or injury in any way related to occupation of deceased NO If so, specify ....
(Signature)
John 7. Collins hat5
M. D.
John F. Collins MD
(Address)
2) Bennington
Revere Mass
.Date.
WINTHULP
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
DEC
2
,65
7 NAME OF
FUNERAL DIRECTOR
MAURICE WITIRBY
ADDRESS WINTHROP
Received and filed
DEC 2 - 1963
19.
(Registrar )
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FEMALE-
9 COLOR
WHITE
10 SINGLE
MARRIED
(write the word)
WIDOWED
DIVORCED
INKNOW
WIDOWED)
11 If married, widowed, or divorced HUSBAND of EDWARD
(Give maiden name of wife in full)
NEGUÉA.
(or) WIFE of
(Husband's name in full)
12
50
AGE
Years
Months. . .
Days
If under 24 hours
Hours ........
Minutes
13 Usual
Occupation.
HOME MAYER
(Kind of work done during most of working life)
14 Industry
or Business
HOME
15 Social Security No MONE
16 BIRTHPLACE (City) E HST 20194 (State or country )
17 NAME OF
FATHER
MICHAEL WINSTON
18 BIRTHPLACE OF
FATHER (City).
IRELAND.
(State or country)
19 MAIDEN NAME
OF MOTHER
MARV MITCHELL
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
IRELAND
21 Informant
EDUARD U RECUENTOP
23 THORNTON, PAPRIY.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Karpu &
(Signature-of Agent of Board of Health or other)
Health officer
die 2. 1963
(Official Designation)
(Date of Issue of Permit)
TVA
2-934553
RM R-301
or burial permit rd of Health Agent. CTIONS OR CERTIFICATE
R TYPE CAUSES EATH
t enter пап опе for each b) and (c)
s not mean of dying, eart failure, c. It means or compli- hich caused
ts, if any, ve rise to anse (a), he under- ause last.
ions contrib- eath but not the terminal dition given n.C
(Print int or Type Nan same ) 30 Nov je 63
WINTHROP7
PARENTS
(Address)
Registered No.
240
2 FULL NAME
HELEN W. (Winston) Keough
(If deceased is a married, widowed or divorced woman, give also maiden name.)
23 THORNTON PARK
St
(City or town and State)
19
(a)
6
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RECEIVED.
11
.POWA 10.1. 12
W
6
5
UP MASS
GLERK
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observandscof the following rules of practice :
Attending physicians will certify to such deaths only as those disease un~ 1982
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.
OFFI
NOW
RM R-301
r burial permit d of Health Agent. CTIONS R ERTIFICATE
R TYPE CAUSES ATH enter an one or each ) and (c)
s not mean of dying, cart failure, c. Il means or compli- ich caused
s, if any, ve rise to use (@), he under- use last.
ons contrib- ath but not the terminal dition given
PLACE OF DEATH
X Suffolk (County) Winthrop 1 (City or Town) 6 Grandview au No.
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
241
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) PHYSICIAN - IMPORTANT
Fannie I Lang
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
10
(a) Residence. No.
(Usual place of abode)
In place of death - years 7 months - days. In place of residence
45 €
.. years ......... months .......
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
That I attended deceased from
August 15,
63
NOV.
`29
19
63
I last saw h ...... alive on
NOV ..... 27,
16.3, death is said to
have occurred on the date stated above, at
1:25p .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
generalized carcinomatosis
(a)
Due Toadenocarcinoma of the
(b)
rectum
Due To
none
(c)
OTHER
SIGNIFICANT
CONDITIONS
none
Was autopsy performed? ... n.O.
What test confirmed diagnosis? Clinical & laboratory
17 NAME OF
FATHER
(C.BL) Jakoritz
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
e. B.L.
20 BIRTHPLACE OF MOTHER (City) (State or country)
Russia
Lebanon Lodge Peabody
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Dec /
1963
7 NAME OF
NERAL
Jor Funeral Survie trc
Chelsea
ADDRESS
Received and filed
NOV 2-9 1963
19
(Registrar)
PARENTSK
21 Informant
John asquith
(Address)
6 Grand View an Wintry
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Roept & Servanne (B) (Signature of Agent of Board of Health or other) Health officer november 2 9, 1963
(Official Designation).
(Date of Issue of Permit)
ik
A TRUE COPY ATTEST:
M. D.
Maurice Traunstein /Jr ..
M.D.
(Address)
73 BarET&EE"PRName) Dat
Nov. 29 63
Winthrop, Mass 102152
6
November
29
1963
8 SEX
9 COLOR
Finale White
10 SINGLE-
MARRIED
(write the word)
Widowg
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
Clarence 2, Lang
(or) WIFE of
(Husband's name in full)
12
82 Years.
.Months.
Days
If under 24 hours
.Hours ...
Minutes
13 Usual
Proprioter
Occupation
8 mos .
(Kind of work done during most of working life)
14 Industry
or Business.
Down Shop
15 Social Security
No 031-14-5759
16 BIRTHPLACE (City).
(State or country )
Russia
5 Was disease or injury in any way related to occupation of deceased? no If so, specify
(Signature)
6 Grandview Que
St
Winthrop, mass
(City or town and State)
INTERVAL BETWEEN ONSET AND DEATH 3 mos AGES.
(Give maiden name of wife in full)
to
2-934553
(City or Town making this return)
2 FULL NAME
WEGE VED
OF
NOW
ER
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE ...
DATE OF DISCHARGE
6
RANK, RATING
ORGANIZATION AND OUTFIT NOV 2 91963 PM
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.
7
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)
242 ....
2 FULL NAME
Christopher C. Nugent
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
11 Bartlett Parkway
St
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months .......... days. In place of residence.
5.0.
ears.
....... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
November 30 1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
Nov. 6. 190319
to.
NOV. 30, 1963
19
I last saw h.LAlive on
27, 70630.
death is said to
have occurred on the date stated above, at : 35 am.m.
INTERVAL
BETWEEN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
ONSET AND
DEATH
1 yr
(a) Arteriosclerotic Heart Disease
5 yrs
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
none
Was autopsy performed?
no
What test confirmed diagnosis ?
clinical findings
5 Was disease or injury in any way related to occupation of deceased ? no If so, specify
(Signature)
John 7 Concluía 715 M. D. fann I. Collins, I.D (Print or Type Name) (Address) 27 Pennington "t
Trong
Data 2/2/63
6
Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
December
3
19
63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O' Maley
Winthrop, Mass.
ADDRESS
Received and filed
DEC 2 - 1963
19
( Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWEWidowed
DIVORCED
UNKNOWN
11 1f married, widowed, or divorced
HUSBAND of
Mary Dempsey
(or) WIFE of.
(Husband's name in full)
12
AGE .. 8.5 Years.
Months ..
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Proprietor
(Kind of work done during most working life)
14 Industry
Motor Transportation
15 Social Security No.
16 BIRTHPLACE (City)
(State or country )
New Jersey
Newark
17 NAME OF
FATHER
John Nugent
PARENTS
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Mary J. Pilkington
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21 Informant
( Address)
John .... Nugent
11 Bartlett Parkway, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E Vivianne (B) (Signature of Agent of Board of Health or other) Health officer December 2, 1963
(Official Designation)
(Date of Issue of Permit)
T. V. D. V
burial permit of Health Agent. TIONS
RTIFICATE
TYPE CAUSES ATH enter in one r each and (c)
not mean of dying, rt failure, ,It means or compli- ch caused
if any, rise to se (a), : under- se last.
ns contrib. th but not e terminal tion given C.
32382
M R-301
1
No ... 11 ..... Bartlett ..... Parkway
f(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
(Usual place of abode)
Registered No.
A TRUE COPY ATTEST:
(Give maiden name of wife in full)
Due Tp
(b) Arteriosclerosis, generalized
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT.
SERVICE NUMBER
RULES OF PRACTICE
he
The fulfillment of the purpose of these laws calls for the observance Q 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 ont related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as thoseof persons who, though disabled by recognized disease unrelated to any forDof injury, have died without recent medical attendance or whose physicianJis 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 bad 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.
OFFIC
10
E
5
10
"
OF
NIE
11 72
TOWN
MASS.
2
GLERK
RECEIVED
M R-302
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
PLACE OF DEATH
Essex
(County)
Denvers
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
(City or Town making this return)
Registered No.
243
[(If death occurred in a hospital or institution, Danvers State Hospital DanversSt. I give its NAME instead of street and number)
2 FULL NAME.
Florence G. Teel
(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
15 Sturgis St. Winthrop Mass.
St
(If nonresident, give city or town and State)
Length of stay: In place of death.
years.
.... months.
Says. In place of residence .......... years ........
months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
August 30, 1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFYA
That I attended deceased frony
April 30 19 61 August 30
19
63
I last saw h ...
.Aire on
ugast
3.0
19 6 death is said to
have occurred on the date stated above, at
8:30 a.
INTERVAL BETWEEN ONSET AND
(or) WIFE
(Husband's name in full)
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