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COMMONWEALTH OF MASSACHUSETTS t~tT
UNITED STATES OF AMERICA K>t~[s i
- 481791
CERTIFIED COPY OF DEATH
FROM THB RECORDS OP DEATHS IN TTiB CITY OF M8DFOIRD
t. Full Name of Decaoed ~ „ 'hOBi?ti:;4?i•
•~..:.Ji„.. .
2. Sex, Colo: and Condicion _ . 7~1'e "W~'ti'CA" ' ~ " :~rrie6' .
3. Date of Death No.
Death ~@G!l'4~eT' . L
4. Place of
'Lewrezice 'Memoridl '~i'oepital'. " Medior'dC; ~ MA'
S. Residence ~ ~
6. Age . ....4~0. ~It011. 'S~Ereiet; ' Msdiord; hIA'
Yesn . Moatla .1_ nap .6.
om,pacion ...R~t~ 'Proprietor 'Super' MarRet...............
8. Social Security No. ............War Service
'o~~=~oao~o~ • No~
9. Bicthpiace . . . H '''~d;..Cl9i>~ifld~i
10. if Married. Widowed or Divorced i . . a
Wife j °f ' l~lorerice' Shea'
1 i. Name of Father - - • . -
GeOY'ge ~~1a ~4b~I1d011
12. Birthpiaae of Father
13. Maiden None of Maher ~
'i~isitu ' i
aii~aaii ~
14. Bicthplatt of Mother ...~8lid ~
s
iS. Informant
'TN~'t ~ ' FIbCe ' ~ubinst3ri; ' ~+:ed~oi~; . M~.......... .
16. Cause of Death . • • •MYOCA~IRI: 'INP'ARCTIOIQ.............................. .
and D~uatian -
i 7. Phys~ian is Atteadaooe ...Jd t~ ' 3AtltCha~t ~ ' M: ?Y: " " L~'t8'~t ~ . MK ' . .
ls. Place of Burial and Date • • •0»t' iGl{di?d' Cacti: ' Medtoi"d'; . 2~iA" " "I~eCember ' 2b;' 1978
19. Undertaker _ ~
~Q~i.~.. 17oio enl tq, tbet I boll tbt office of City CINg of
the City o~,~,~.~~c~urt~o~.
MiJdTisx, Coaroroarwaltb. of MouarbutNtf, al -that tbt rtcorlt of Dir~ebJ iw tal
Citr ere ix my awttai~,'~~lLir xinvo u s trw txbeet front toil ncorlt, tt to?Nfiwl J?y arc.
i. _ _
. ' ~ WITNESS my hand and the sal of said on the ~ 9th day
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