REGISTRY DIVISION OF THE CITY OF BOSTON COUNTY OF SUFFOLK COMMONWEALTH OF MASSACHUSETTS. UNITED STATES OF AMERICA BOSTONIA Certificate XP 40412 CONDITA & 1830 I, the undersigned, hereby certify that I hold the office of City Registrar of the City of Boston and I certify the following facts appear on the records of Births, Marriages and Deaths kept in said City as required by law. The Commonwealth of Massachusetts BOSTON Suffolk SECRETARY OF THE COMMONWEALTH (City or Town making this return DIVISION OF VITAL STATISTICS (County) RM R-301 Boston STANDARD 04458 (City or Town) CERTIFICATE OF DEATH Registered No. Iled for burial permit No New England Deaconess Hospital (If death occurred in a hospital or institution St. h Board of Health give its NAME instead of street and number) or its Agent. PHYSICIAN-IMPORTANT TRUCTIONS FOR Mrs. Mary Chamberlin (nee Marr) (If deceased a CAL CERTIFICATE 2 FULL NAME (If deceased is a married, widowed or divorced woman give also maiden name.) U. S. War Veteran, specify WAR) RINT OR TYPE 31 Red Coat Road USE OR CAUSES (a) Permanent Residence No. St. Westport Conn. (City or town and State) OF DEATH UNFADING BLACK OR APPROVED MEDICAL CERTIFICATE OF DEATH PERSONAL AND STATISTICAL PARTICULARS CK TYPEWRITER RIBBON 9 SEX 10 COLOR 11 SINGLE (write the word) 3 DATE OF June 17 1977 MARRIED DEATH (Month) (Day) (Year) Female White WIDOWED Married DIVORCED 4 H E R.E.B Y CERTLEY. that 1 attended deceased from UNKNOWN May 19 77 to June 19 77 12 If married, widowed. or divorced I last saw h 3ralive on June 17 1977. death is said to HUSBAND of have occurred on the date stated above. at 8:21 a. m. INTERVAL (or) WIFE of C. Wilson (Give Chambe name with in full) is does not mean the mode of BETWEEN DEATH WAS CAUSED BY: IMMEDIATE CAUSE ONSET AND (Husband's name in full) JUCA as heart failure. aithe. DEATH etc. " means the disease, or lications which caused death (a) CARCINO TUMOR 13 AGE 57 Years 9 Months 14 Days If under 24 hours 13 ups, Hours Mia: aditions, if any, which gave Due To 14 Usual a above cause (a). stating the Broker (b) Occupation lying cause last. (Kind of work done during most of working life) Due To 15 Industry (c) or Business Real Estate aditions contributing to death OTHER 101 related to the terminal dis- SIGNIFICANT 16 Social Security No condition given in (a) CONDITIONS 17 BIRTHPLACE (City) Was autopsy performed? yes (State or country) Westbrook, Maine What test confirmed diagnosis? Biopsy 18 NAME OF 5 Was disease or injury in any way related to occupation of deceased? No FATHER Wade H. Marr S 19 BIRTHPLACE OF FATHER (City) Sweden If so, specify (State or country) Maine % 211.3 3 (Signature) Parrience Pleno w 20 MAIDEN NAME M.D. 06 OF MOTHER Frances Spurling LAURENCE P. CLOUD 21 BIRTHPLACE OF (Print or Type Name) Portland 110 Fauster's Sr, BOSTONEZ Date 6/17/1777 a MOTHER (City) (State or country) Maine 22 I HEREBY CERTIFY that a satisfactory standard certificate of de 6 Mt. Auburn Crematory Cambridge was the burial or transit permit was issued Place of Burial or Cremation (City or Town) DATE OF BURIAL June 20 1977 07 NAME OF Mary filed/with Designation) me (Signature BEFORE of Axpert Board (Date of of Health Issue 18, of 21891 Permit) other) 197 or Frank A. McDonald, Jr. FUNERAL DIRECTOR (Official ADDRESS 495 Comm. Ave., Boston, Mass. 23 JUN Received and filed 19 & Informant Mr. C. Wilson Chamberlin R-301. 175M-6-76-128807 (Address) 31 Red Coat Rd., Westport, Conn. William Hair (Clerk or Regist I further certify that by annexation, the Records of the following-named cities WITNESS my hand and the SEAL of the CITY REGISTRAR and towns are in the custody of the City Registrar of Boston:- ANNEXED East Boston on this 1637 26 Day of JUL A. D. 1977 South Boston 1804 Roxbury 1868 Dorchester 1870 William Kame Charlestown By Chapter 314 of the Acts of 1892, "the certificates or attestations Brighton 1874 of the Assistant City Registrars shall have the same force and effect as West Roxbury that of the City Registrar." Hyde Park 1912