USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1958 > Part 27
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HUSBAND of
(Give maiden name of wife in full)
(or) WIFE Lenas E.
(Husband's name in full)
MEDICAL. CERTIFICATE OF DEATH
1958
J(If death occurred in a hospital or institution,
St. ( give ita NAME instead of street and number)
PHYSICIAN - IMPORTANT
( Wan deceased a U. S. War Veteran,
so specify WARI
(a) Rendence. No.
( l'qual place of aboute)
Registered No.
INTERVAL DETWEEN ONSET AND DEATH 3 MRS
DAYS
١
RM R-301A - X suffolk (County)
PLACE OF DEATH
Boston (lite of Town) New England Deaconess Hospital in . Lucy Pepicolli ( If deceased is a married, widowed or direcent orman, five also maiden name)
Chr Commamoralth of Massachusetts EDWARD J CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
67
To be a :- 4 for bursl permit with Red of Health et its Agent
Registered in 01572
If death occurred in: a F .pital of er ... . ;!! ( .
PHYSICIAN IMPORTANT
. War beieran. -
s. inthron, : 855. ( a) Residence. Il qual place et aboules
Length of stay in piace of death vrate months 5 data In place of residence
weare
PERSONAL AND STATI-TO AL PARTICI LARS
9 COLOR
£
(write the word)
female
white
carridd
Ins it married withart. It : rise of
i.s. mader same et wale in full
have occurred in the date atated alese, at 11:00 am
DEATH WAS CAUSED BY. IMMEDIATE CAUSE ARTERIOSCLEROTIC HEART EASEASE
Due To DIABETES MELLITUS
Due To 10)
SE. VIFICANT HIATUS HERNIA UNDNESS, DUE TO B. No ELECTROCARDIOGRAMA What teat cesiummed diagnosis
15 YRS 10 yas
", NAME OF
Italy Joseph Carpinito
IF BIRTHPLACE OF FATHER /4 19 ..
Italy
J. Donald Ostrow
I Signed J. Donald Ostrow MU
NEW ENG. DEACONESS HOUP. 2-12 10 58
Winthrop Cemetery, Winthrop Je at Hunstar tremal un
DATE OF BIRIAL February 15, 19 53
Ernest P. Corciano FINERAL DIRECTOR 147 Winthrop St., Winthrop
1.
6215
9-12-58 (Date of Issue of Primit;
etHft, ta førstanation ;
1
D ...
Hour. Minutes
1} {'qual
Housewife
Ocupation
( Kind or area done during most of working live!
14 industry or Business at home
is vaial Security Nn.
NONE
16 BIRTHPLACE (CITY)
PARENTS
IS MAIDEN NINE OF MOTHER Irene Buonorane
NURINPLACE OF MOTHER .....
Italy
ותגותיו '.1 William J. Pepicelli 51 Banks St. Winthrop
› (İkTIr\ t'at a sat "+ The REFI.RF the dendo
. Tandard estibeate at death tra. . ............. UP
.
..
-
INTERVAL BETWEEN ONSET AND DEATH
11 IF STILLBORN. enter that fact beir
13 NOS. 12
77
AGF. Years Months 17.
If under 24 hours 1
13 YRS.
9
.
Chapter 137, 1 1694, requires iens to print of the cause of of death on
15.
5 1958
STRUCTIONS FOR AL CERTIFICATE
In giving E OF DEATH MEDICAL CERTIFICATE OF DEATH DATE OF DFATHI
1958
That I attended drieated in m
-
not enter re than one se for each ). (b) and (c)
. ........
.....
10
. it otin of terraced
No
.
FULL NAME
ilf nonresident & ve city o' town and State )
50 Petruurs 7 Te. runr. I last sam h Clate an Fas Tutry It , 10 00, death is mal !!
Antonio Pepicelli iHusband · name in tull,
MAY-50 1
68
01799
Peter Rent Brigham Hospital
Ralph Shorey -- Ralph Winthrop chorey . a married. as ! weg or dirneced .
give aiso maider rame !
-
12 Cottage AVE.
Winthrop, Nass.
(a) Residen. . ('qual place of aboute)
(If , cent. give ( of town and State )
15 Mins. 75 ..... place of residence morthe
PERSONAL AND STATISTICAL PARTICULARS
A DATE OF DEATH
February
18
1958
15-20)
That D attended de rased from
Feb. 18
58
ing If married, wido wed, at divorced HUSBAND LV01372740723
Chaise maiden name of wife in just
for) WIFE of
iHnv.and's name in full)
11 IF STILLBORN, enter that fact here
12 NGE 75 Years 7 Months
If weiter is hours Hours Minute.
Orcupatı' n ilin Cler .:
. Kind of arts tone during most of working itfe)
14 Intu ...
INKial Security \
16 HIRTHPLACE KCITY1
1. SAMT OF FATHER Charles Cherny
1* HIRTUTLACE OF
What test confirmed diagno ... .
Autopsy
S Was disease or fijury in any way related! An in cupation of drieased. HO
Victoria
(Signed) . MD (Mere :. Bent Brechen Hosp man Feb. 19 1.58
Winthrop Cometer: "inthron
l'lare of Iturial or Cremation
DATE OF RI RINI
alfred 13. March
FINIRAL DIRECTO
ADDRESS174
.
PLACE OF DEATH
Suffolk { County )
Boston (City or Town)
The Commonwealth of Massachusetts EDWARD J CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Registered Va
Fattet an! !! mbert
IMPORTANT
2 FULL NAME .
TO.
(If derase i
RUCTIONS FOR CERTIFICATE Length of stay In plate of death
OF DEATH
ot enter than one for each (b) and (c)
- AWOHEREBY CERTIFY, Feb. 18 10. 58
Feb. 18
1058 . death 14 43. 3 fr|
1:45 Pm
have ocurre I on the date stated almise, at
DEATH WAS CAUSED BY : IMMEDIATE CAUSE CardiAc TEMPONAVE
Following himogErinardium ication; AWell BYSm B .- To Dissecting Forthe Hiveurging (dissection iEnto PERicArdiAM). PERileadium
Due In
-----
........ ......
4 apter ir. 1954. requires ins to print of ir cause of of drab oc rtincates -
1
...... ..
BIRTHPLACE OF WOTIIER ( !* ) Charlestown "'1.
..
10
anlat certificate of death
Janull In mac 6325 ..
2-20-8 (Date in loque . t f'ermiti
& SEX & COLOR
(write the word)
(Month)
:hito
MAKRITO wirried
o. DIVORCED
kraft
, .. ......
10
...... .....
.. ..
......
SIGNIFICANT CONDITIONS
Yes
FATHER .( ... )
BEIDES SIVE MF MOTHER PYthA FallIn
FEB 1998211900 Charles H. IMachen"
5 1958
い
1 R-301A
--.
. War Veteran. -
months
MEDN'AI. CERTIFICATE OF DEATH
INTERVAL BETWEEN ONSET AND DEATH 1hr.
X
RMI R-303 B W6B
Fuery itoni of of Death. See reverse site for extracto from the laws relative to the return of certificates of death. DEATH in plain terms. on that it may be properly classified under the international Classification of Callees information should be carefully supplied. MEDICAL EXAMINERY should .ale CAUSE AND MANNER OF WRITE PLAINLY. WITH UNFADING BLACK INK THIS IS A PERMANENT RECORD
...... .......
PLACE OF DEATH
Suffolk
Boston
The Commonwealth of Masssrbasris EDWARD J CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
69
)183
Pestered \
Veterans Administration, Hosp.
ive its NAME Ingest a street and nurbe:) -
..
USWY & WVI
68 Redlands Road, West Roxbury ...
Length of residence in, "ty or towr where did't our !! yrs 6
PERSONAL AND STATISTICAL PARTICULARS
S SINGLE MARRIED WIDOWED DIVORCED
Widowed
Ilinna mozabeth G. Wilson HUSBAND of
Ctive marten name ol wife in fun;
Hushan'ı name in fult!
years
8 .. 86 AGE Year 7 Months .7 Days
If less than i dey
Hours
Minutes
Usual
Letter carrier-Retired
Social Security No 012-20-8960 -
12 BIRTHPLACE City (State or enintryi Mass
13 NAME OP PATHER Dennis Dwyer
14 BIRTHPLACE OP FATHER ICHty! State of courtry . Ireland
15 MAIDEN NAME. OP MOTHER Mary (CBL)
BIRTHPLACE OP MOTHER KCity' State (r .ountry Ireland
17 James J. Dwyer informar
Nephew"
68 Redlands Rd. , W. Roxbury
! UPPONY ( FHTIPY, that a satisfactory standard certificate of death was
(6354
2-21-08 Dave if lame of Perm:t
& DATE OP DEATH
February 19
1953
(Year.
19 I HEREBY CERTIFY that I have inies: paint the frath of the person atave name! and that the CAUSE AND MASSER theseol are as follows (I! an injury was involved, state !! " Fracture of skall.
Accidental fall presumably at home Boston 0/7 2-18-58.
20 IN WHAT DAY OR T WAS INTUIN SISTATNE
-
10.
-20-53 19
Acirem
Date
21 PLACE. OP BURIAL Winthrop Cemetery CREMATION OR REMOVAL. Camurry
Winthrop DATE OF BURIAL February 22nd 1958
NAME OF UNDERTAKER Richard C. Kirby ADDRES 917 Bennington St., E. Boston
1958
Boreived and first
19
X
John J. Dwyer 2 PULL NAME
( !! dereactie a married, and we ! e d'unpred " man are also marten rate) TU S .- Vete. i if so iparfy WAR)
(if nor pillent gire aty or then and State)
days
MEDICAL CERTIFICATE OF DEATH
(a) Residence ( l'susi place of stone) 1 SEX COLOR OR RACE Wale White for) WIPE of 6 Age of hustand or write if alive 9 Occupation. Industry Postal 10 or Buuneu Boston PARENTS 1' tareasel mas a l' S. War Veteran. GL Chap 46. Section 10. requires phyvilar in desert a pessoal to that effe? 7 IP STILLBORN, enter that fact here
,
D
6
.
X
PLACE OF DEATH
SUFF^LX (County ) BOSTON (City or Town)
The Commonwealth of fassartisttts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be fl'ed for bartal *aft with Board of Health ar its Agent.
Registered Nn
01936-
St (give it. NAME. instead of street and number) No CASSACI
2 FULL NAME
T. NJAYIN SMITH
( If deceased is a married, widowed or divorced woman, sire also maiden name )
6 CENTRAL STREET
( a) Residence. No
S
( I'sual place of atode)
Length of stay: In place of death
year.
months 10 days In place of residence 2 years - months
WINTHROP,
MASS.
(If nonresident, give city of town and State)
- days
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
J DATE OF
DEATH
FEBRUARY
24
1958
(Month)
(Year)
(D))))
That liBlended deceased form
Feb. 24,
58
WClast .aw b AMalive on
Feb. 24,
. 1º 53.
. death
have ocurre.l on the date stated atweise. at 2 :40A .-
DEATH WAS CAUSED BY : IMMEDIATE CAUSE Acute Myocardial Infarction
Due To Coronary Heart disease
(h)
Due To (1)
OTHER SIGNIFICANT Lothar pneumonia CONDITIONS Anacria, secondary
(appro 22ks
6 mos.
Was autopay performed?
What test confirmed diagnosis'
5 Was dieease of injury in any way related to occupation of deceased' If .o. . perify
2
(Address) Asst . Dir.Mass .Gen' IDate
19
Yinthron
Winthrop 12 gs it .t. or Treni
l'lace nf Rurial of t'rematien
DATE OF BIRIAL.
February 26.
158|
Geneyleye 6 Contrat st: . winthrop_Mass,
FKFISKERTIES that a batista lose standard certificate of death
* meade is anause it Isens of Hoved at Stealth or other
6383 (tithotel Designation !
2-25-58
" Date of leave oil l'etmit)
V.I.V
divorced
Genevieve A. Wulloy tGive maiden name of wife in full)
(or) WIFF of
( Husband's name in full)
11 IF STILLRORN enter that fact here
2 wks.
12 AGF72 Years
If under 24 hours Hours Minute.
Occupation
Retired Rizver ( Kind of work done during most of working life)
14 Industri
Buure ..
Shipbuilding
IS Social Security No.
023-10-5799
16 BIRTHPLACE (City)
Winthrop
.98
.1; NAME OF
Willard Smith
i* BIRTHPLACE OF
FATHER (Ct))
Provincetown
VADES NAME tt MOTHER Emma F. Paine
MI)THER ( ... )) Winthrop
FINERAL DIRECTOR Arthur J. O'Laley ADDRESS Winthrop.' FLO 21 1558 Charles A. IM and 19 strati
& SEX
Male
9 COLOR
.10 SINGLE. (orite the word)
White
MARRIED
WIDOWED
Of DIVORCEDArried
4I HEREBY CERTIFY
Feb. 14, 0 58
12
INTERVAL
BETWEEN
ONSET AND
DEATH
approx.
Unk. vrs
(to mult. papillomata of orina . stauder
PARENTSI
af death on ert.Acates
1
10
1
....... death bot mot
Chapter 17. 1994, requires aos ta print of
M R-301A
TRUCTIONS FOR L CERTIFICATE
OF DEATH not enter e than one e for each · (b) and (c)
PHYSICIAN - IMPORTANT
illas decreased a . 1
S
War Veteran,
No
1! so specify WAR).
fiIt death occurred in a hospital or institution.
ISENTA GENERAL HOSPITA L
2/24/ 59
10a If married.
HUSBAND of
MAY-21900 11
F
A pł death ( of an t the dec best of disease contrac or offic
A pl precedi teen, sl army, 1 engage shall al diate c; with an For the of said ‹ relief ex deemed ninety- service G. L. C'
No u in a tow has rece such pe person remove other tl receivec of the tr shall ha a satisf returne‹ ment, b' law, or i physicia enough of healt applica1 caused permit 1 to anot purpose the und remova remove form fo
SPA( DAT DAT RAN ORG SER',
X PLACE OF DEATH
Suffolk (County)
CENSE FINDER
The Commonwealth of Massachusetts EDWARD J. CRONIN 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.
71
§ (If death occurred in a hospital or institution,, St. ¿ give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
10 Orlando Ave
St
(If nonresident, give city or town and State)
Length of stay: In place of death
years ..
.months.
days. In place of residence
.years
months ..
........ days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
April
3, 1958
DEATH
(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 10:55 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Natural Causes
INTERVAL BETWEEN ONSET AND DEATH
Due To
Presumably Coronary
(h)
Occlusion
(c)
Due To Arteriosclerotic Heart
Disease
years
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed? no What test confirmed diagnosis? post-mortem judgement
5 Was disease or injury in any way related to occupation of decreased? no If so, specify ..
(Signed)
arthur C. Murray
D.
Winthrop Board of Health
1958
6 Holy Cross Cemetery Malden Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL April 7 19.5.8
7 NAME OF
FUNERAL DIRECTOR.
Arthur J. O'Maley
ADDRESS Winthrop Mass
Received and filed
APR 4 1958
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
single
10a If married, widowed, or divorced HUSBAND of ... (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
69
AGE
Years
.Months.
.Days
If under 24 hours
Hours ........
Minutes
13 Usual
Occupation :
Retired Clerk
(Kind of work done during most of working life)
14 Industry
or Business
Brokerage
15 Social Security No ....
16 BIRTHPLACE (City)
(State or country)
Eagt Boston
Mass
17 NAME OF FATHER Andrew J. Howard
18 BIRTHPLACE OF
Boston
FATHER (City).
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Mary A. Baldwin
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mags
East Boston
21 Informant (Address)
Mrs Martin Cain 21 Orlando Ave Winthrop
WHEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of llealth or other) Health Picie 4/4/58
(Official Designation )
(Date of Issue of /Pernft)
"UCTIONS :OR CERTIFICATE
giving OF DEATH ot enter than one s for each 1.b) and (c)
s'oes not mean ¿? of dying, sieart failure, aetc. It means re, or compli- which caused
ins, if any, ave rise to cause (a), the under- ause last.
'ions contrib- cicath but not the terminal dition given
E Chapter 137, o 1954, requires dns to print or e cause or sof death on
Certificates.
100M.11.55-916145
] R-301A 1
Winthrop (City or Town)
No.
10 Orlando Ave
2 FULL NAME LouisA Howard
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. (Usual place of abode)
50
15
PARENTS
Registered No.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.
C
O P t a e S
d F O d n
S G
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- te n, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health. or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six. that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies of persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. .- General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such bbard, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made.
Chap. 114, Sec, 46, G. L., (Tercentenary Edition).
11.12
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow- ing rules of practice:
(1)' Atfending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated 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 Emariners 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 occupation, 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 import- ant, 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. Children 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.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
I
I
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
J) SERVICE NUMBER
h: S1
01 L of sł a re
m la p er
of CE
tc P tl re fc
S
F
C
C t 1
X
[ R-301A 1
... PLACE OF DEATH Suffolk (County) Winthrop (City or Town)
26 Enfield Bo.
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
No. 1 homas J. Mulcahy 2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
26 Enfield Rd.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death 35 .years .months. days. In place of residence.
35
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
4 I HEREBY CERTIFY,
That I attended deceased from
Jan.
1955
19
to ..
April 4 1
1958
I last saw h ~ alive on
April 3, 1958, death is said to
have occurred on the date stated above, at.
8 A
.m.
INTERVAL BE-
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE ..
r/ 1 years
.Months
.Days
If under 24 hours
Hours ...
Minutes
13 Usual
Occupation :
Salesvian
(Kind of work done during most of working life)
14 Industry
or Business:
Hosery Hesiery
15 Social Security
183-07-1940
16 BIRTHPLACE (City) ..
(State or country)
plass
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation
Was autopsy performed?
What test confirmed diagnosis ?.
EKG
5 Was disease or injury in any way related to occupation of deceased? no
If so, specify.
(Signed)
M. D.
(Address) 30 FTClubes
6 St Protis Cemetery Arlington
Place of Burial or Cremation (City of Town)
DATE OF BURIAL . April /1 1958
7 NAME OF
FUNERAL DIRECTOR,
ADDRESS REL Deckel St
Received and filed
April 1,
958
(Registrar)
PARENTS
18 BIRTHPLACE OF FATHER (City) (State or country)
Telaria
19 MAIDEN NAME
OF MOTHER
Bridget O' Brien
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21 Informant (Address) 26 Fufield Rd Winterou
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
4/7 /58
(Official Designation)
(Date of Issue of Permity
UCTIONS FOR CERTIFICATE
living OF DEATH ot enter than one for each b) and (c)
does not mean of dying, such Uure, asthenia, ins the disease, › ations which . h.
1 conditions. ng rise to the : (a) stating ilying cause
tions contrib- death but not the disease or lausing death.
Chapter 137. 1954. requires Ins to print or pause or causes h on death cs.
50M-5-55-915025
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Coronary Thrombosis
TWEEN ONSET ANO DEATH
2 days
ANTE
CEDENT (b)
CAUSES
Due To
Arterio Sclerosis
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