USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 53
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(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
Suffolk (County)
Winthrop (City or Town)
No.
142 Pleasant ..... S.t.
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
213
[(If death occurred in a hospital or institution, St. } give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
Katherine. ... Mackinnon
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
556 Shirley St.
.St
(If nonresident, give city or town and State)
Length of stay: In place of death ..
.years.
50
months.
16
days.
In place of residence.
.years
.. months ..
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
November 10, 1960
DEATH
(Month)
(Day)
(Year)
4 I
HEREBY CERTIFY,
That I attended deceased from
8124 19:5%
...... to ..... 10
60
I last saw heralive on
9
1960
death is said to
have occurred on the date stated above, at
10:50 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cerebrovascular accident
Due To
(b)
arteriosclerosis
Due To
generalized
(c)
Senility
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
/20
5 Was disease or injury in any way, related to occupation of deceased?
If so, specify Joseph, GreGRIE
PARENTS
Winthrop Cemetery
6
Place of Burial or Cremation
(City or Town)
Winthrop
DATE OF BURIAL
November 14
19
60
7 NAME OF
FUNERAL
DIRECTOR
Arthur J. O'Maley
Winthrop Mass
ADDRESS
Received and filed
NOV-14-1960
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEgle
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
67
Years.
Months.
.. Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry
or Business :
Dress Maker
15 Social Security No. Cape Breton
16 BIRTHPLACE (City)
(State or country)
Nova Scotia
17 NAME OF
FATHER
Dougal Mackinnon
18 BIRTHPLACE OF
FATHER (City)
Cape Breton
M. D
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Margaret Maceachern
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
Cape Breton
21 Isabelle Mackinnon
Informant
(Address)
556 Shirley St. Winthrop
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)
11/14/60
(Official Designation)
1
.
(Date of Issue of Permit)
X
60-928145
M R-301A 1
STRUCTIONS FOR AL CERTIFICATE
In giving E OF DEATH not enter re than one se for each ), (b) and (c)
does not mean ode of dying, s heart failure, 2, etc. It means ease, or compli- which caused M.S.
itions, if any, h gave rise to e cause (a), ag the under- cause last.
nditions contrib- o death but not to the terminal condition given
te :- Chapter 137, of 1954. requires icians to print or the cause or es of death on certificates, and ter 48, Acts of requires Physi- to print or type under signature.
(PRINT OR TYPE SIGNATURE)
(Address) Giltla
Date.
11/12
198
INTERVAL BETWEEN ONSET AND DEATH
To be filed for burial permit with Board of Health or its Agent.
[(Was deceased a { U. S. War Veteran,
{if so specify WAR)
(a) Residence. No.
(Usual place of abode)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
OFFICE 0
TOWN
1.12 ...
9: ¥3)
CLERK
5
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.
NOV 141960 AM
6
ORM R-304
PLACE OF DELIVERY No.
SUFFolk (County )
1 WINTHROP (City or Town )
Winthrop Community.
2 NAME OF FETUS (if given)
Baby girl Reynolds
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH (STILLBIRTH)
To be filed for burial permit with Board of Health or its Agent.
Registered No.
2.4.1
(If death occurred in a hospital or institution, give its NAME instead of street and number)
3 DATE OF
DELIVERY
Nor ( Month )
11.1960 (Day)
(Year )
4 SEX
Male ...... FemaleY .. Undetermined
5 COLOR (if
determined) W
6 THIS BIRTH (Check one)
Single\ .. Twin
..
-Triplet
7 IF MULTIPLE BIRTH, BORN: 1st ... .. 2nd ..... .. 3rd.
FATHER
8 FULL NAME John J. Reynolds IN
14
MAIDEN NAME
MOTHER
Marianna Peralta
PRESENT NAME Marianna In Reynolds
9 RESIDENCE, NO. 110 Constitution Av
STREET
CITY OR TOWN Revere 48 STATE Masi
15
RESIDENCE, NO. 115 Constitution Dvd
CITY OR TOWN
STREET
10 COLOR OR
RACE.
11 AGE AT TIME OF
THIS DELIVERY
47 (Years)
16 COLOR OR RACE W
12 PLACE OF BIRTH Somerville (City or Town)
Mass (State or country )
18 PLACE OF BIRTH Swampscott Mass
(City or Town
(State or country)
13 OCCUPATION clerk
19 INFORMANT husband
20 PREVIOUS DELIVERIES TO MOTHER (Do not include this fetus)
(a) How many children are
now living?
(b) How many children were born alive but are now dead?
(c) How many previous fetal deaths of ANY gestation age ?
21 LENGTH OF PREGNANCY 40 completed weeks
22 WEIGHT OF, FETUS 2 Lb. 14 Oz. (or ... Grams )
23 WHEN DID FETUS DIE? Before Labor ..
During Labor, or Delivery. Unknown
24 AUTOPSY
Yes
No. L
25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE. (a) Pressure of love on Symphypes Due To (b) Breath Presentations Due To (c)
OTHER SIGNIFICANT CONDITIONS
Holy CROSS SemeToRy
MALdew (City or Town)
DATE OF BURIAL
Place 9 Burial or Cremation November 14 1900
27 NAME OF ADDRESS FUNERAL DIRECTOR William J.fillion ISPRAGue ST Revere
Received and filed NOV 14 1960 19
(Registrar )
A TRUE COPY ATTEST :
I HEREBY CERTIFY that this delivery occurred on the date stated above at 3.3 ..... m., and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner : M.D. a Paul Duuttagopicina A Paul PERHAGOPIAN (PRINT OR TYPE SIGNATURE) e: 39 CARYA CHELSEA Date 1- 11- 1960
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued: 1
Talkh & Pereasily
(Signature of Agent of Board of Health or other)
11/14/00
(Official Designation) v (Date of Issue of Permit )
In giving CAUSE OF ETAL DEATH
do not enter more than one cause for each of (a), (b) and (c)
etal or maternal ondition causing tal death (do ot use such rms as stillbirth · prematurity. ) etal and/or ma- rnal conditions, any, which gave se to above use (a), stating e underlying use last.
onditions of fetus mother which ay have contrib- ted to fetal ath, but, in so r as is known, ere not related cause given ( a).
A
4 -
5M-6-60-928241
E
St.
1
MASI 17 AGE AT TIME OF ? (Years) THIS DELIVERY .S STATE.
RECEIVED
TO!
11
FETAL' DEATH
KLERK
0
"
.5 €
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46.A AMENDED OR ADDED BY CHAPTER 48,
ACTS OF 1960.
Section 2A. "Examination of records al@Velut1960 illegitimate births, or abnormal sex births, or fetal deaths, ... shall not be permitted except ... ".
Section 9A. When a child is born dead, after a period of gestation of not less than twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and no movement of voluntary muscle, the physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.
Section 12. " ... No birth record of a child born out of wedlock or of a child of abnormal sex, and no record of fetal death shall so be transmitted to any other city or town."
Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.
X
PLACE OF DEATH
SUFFOLK (County)
WINTHROP
(City or Town)
No.
79 Revere St
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH Registered No.
245
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Thomas Scarpas
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
79 Rovore St
St.
(If nonresident, give city or town and State)
Length of stay : In place of death .... 12 .years .... ... months ... days .. In place of residence. years. .. months ... ...... .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
-
WIDOWED Married
or DIVORCED
10a If married, widowed,jogdivorAkides 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
65'
9
AGE
Years
Months.
Days
If under 24 hours
Hours ...........
.Minutes
13 Usual
Restuarant Monager
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Food
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Greece
17 NAME OF
FATHER
Arthur Scarpas
18 BIRTHPLACE OF
FATHER (City) (State or country) Greece
19 MAIDEN NAME OF MOTHER Unknown
20 BIRTHPLACE OF MOTHER (City) (State or country)
Greece
21 Mrs Thomas Scarpas
Informant
(Address)
79 Revere St Winthrop Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
7 NAME OF
FUNERAL DIRECTOR
Ernest P Caggiano 147 Winthrop St, Winthrop
ADDRESS
Received and filed
NOV 14 1960
19
(Registrar)
PARENTS
M. D.
Arthur C Murray . M. D.
(PRINT OR TYPE SIGNATURE) 100 waldemar le Nov 12 60 (Add Winthrop Board of Heal)
Inthrop Mass
6
Winthrop
Place of Burial or Crematym
DATE OF BURIAL
Nov . 15
(City or Town) 60
19
(Year)
4 1
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 1:30 A.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Natural
Causes
INTERVAL BETWEEN ONSET AND DEATH
Due To
(b)
Presumably Coronary
Occlusion
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
None
Was autopsy performed ?
no
What test confirmed diagnosis? post mortem judgement
5 Was disease or injury in any way related to occupation of deceased ? mo If so, specify
(Signed
ditions, if any, ich gave rise to ve cause (a), ing the under- ig cause last.
Conditions contrib- to death but not d to the terminal e condition given
e :- Chapter 137, of 1954. requires cians to print or the cause or s of death on certificates, and er 48, Acts of requires Physi- to print or type under signature.
M-11-59-926662
(Official Designation) 1
V
(Date of Issue of Permit)
NSTRUCTIONS FOR CAL CERTIFICATE
3 DATE OF
DEATH
November
12
1960
(Month)
(Day)
(Usual place of abode)
017
To be filed for burial permit with Board of Health or its Agent.
(Was deceased a U. S. War Veteran, if so specify WAR)
(Signature of Agent of Board of Health or other) y =C
11/14/60
RM R-301A 1
In giving SE OF DEATH do not enter ore than one use for each a), (b) and (c)
's does not mean mode of dying, as heart failure, tia, etc. It means isease, or compli- s which caused .
Sudden death
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
OF
TOWA
il
III ERK
6
WINTHROP.
RULES OF PRACTICE NOV 1 41960 AM
The fulfillment of the purpose of these laws calls for the observance of 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
Suffolk
(County)
Winthrop
(City or TownBAY VIEW NURSING HOM OME
41 Washington Ave S(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) No.
PHYSICIAN - IMPORTANT
2 FULL NAME
Theresa Fogel
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
{ (Was deceased a U. S. War Veteran,
lif so specify WAR)
19 Frawley St
St.
Roxbury. .... Mass
(Usual place of abode)
Length of stay: In place of death
5
.. months.
.days. In place of residence.
80
.. months ..
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
November 16 1960
DEATH
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY
That I attended deceased from
June 18,
19 ..
5.7, to ....
November 16,
19 60
I last saw heralive on
.November .... 15 ...... , 19 .. 60 .. , death is said to
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
AGE
Years ..
Months ...
.. Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
At Home
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
None
CONDITIONS
disease
3 yrs
Was autopsy performed?
no
What test confirmed diagnosis?
clinicaland laboratory.
5 Was disease or injury in any way related to occupation of deceased? NO. If so, specify
(Signed) M. Transporte M. D M. Traunstein Jr., M. D. (PRINT OR TYPE SIGNATURE)
(Address) 7.3 ... Bartlett .... Rd. Date .... No.v ....... 16 .... 19 .. 60 ..
Winthrop, Mass.
6
New Calvary
Boston.Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
November 18
19 60
7 NAME OF
FUNERAL
DIRECTOR
Arthur J.O'Maley
ADDRESS
Winthrop Mass
Received and filed NOV 17 1960 19
(Registrar)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Cannot be learned
19 MAIDEN NAME OF MOTHER Josephine
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Cannot be learned
21
Informant
(Address)
Frank Gorman 19 Floyd St. Winthrop
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)
11/17/60
(Official Designation)
(Date of Issue of Permit)
X
TRUCTIONS FOR L CERTIFICATE
n giving OF DEATH not enter e than one se for each , (b) and (c)
does not mean de of dying, heart failure, , etc. It means ase, or compli- which caused
tions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not to the terminal condition given
e :- Chapter 137, of 1954. requires cians to print or the cause or s of death on certificates, and er 48, Acts of requires Physi- to print or type under signature.
60-928145
L'ins Tore
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.
246
Registered No.
(write the word)
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
of DIVORCED
Single
have occurred on the date stated above, at 5:15 A.M. INTERVAL BETWEEN ONSET AND DEATH 2 wks 90
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Bronchopneumonia rt lung
Due To
(b)
Due To (c)
OTHER
SIGNIFICANT
Arteriosclerotic ... heart
Boston
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
Adam Fogel
Atty
(a) Residence. No.
(If nonresident, give city or town and State)
M R-301A 1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
RECEIVED
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TOWN
11.12
CLERK
1.1
5
6
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the obsedAnte pf 14960 PM 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 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.
MIN 31
X PLACE OF DEATH
Suffolk (County) Winthrop (City or Town)
112
Brookfield Road
No. .. James t. Reddy
2 FULL NAME
(If deceased is a married, widowed or divorced woman, giye also maiden name.)
(a) Residence.
No.
112
Brookfield &
St.
Road
(If nonresident, give city or town and State)
Length of stay: In place of death
years.
months.
days. In place of residence + years.
9
.. months.
18 days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
November 19
EC
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
/1 21, 1960
to
Nov. 19, 1960
I last saw hanalive on
2202.15
19 60, death is said to
have occurred on the date stated above, at
4 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute Coronary Miranda
Due To
(b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? 270 If so, specify
(Signed)
Marsica 4º Lesser, M. D.
(Address).
Date. .19 66
6 Place of Burial or Cremation tenthich (City of Town) Mass DATE OF BURIAL november - 2, 19.50
7 NAME OF
FUNERAL DIRECTOR
Maurice 21. Kirby
ADDRESS
210 Henthop At Minthop, Mark
Received and filed now. 22 1940
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10-SINGLE
(write the word)
MARRIED
WIDOWED
Or DIVORCED
Married
10a If married, widowed, or divorced __
HUSBAND of
Margaret Wilkinson
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE _____ Years.
Months
Days
If under 24 hours
Hours ...... Minutes
Sales men
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
Zaundry supply
15 Social Security No ..
028-21-25-69
16 BIRTHPLACE (City)
(State or country)
.Mais.
17 NAME OF
FATHER
Thomas A. Reddy
18 BIRTHPLACE OF
FATHER (City)
(State or country)
cheland
19 MAIDEN NAME
OF MOTHER
Joanna Holan
20 BIRTHPLACE OF
MOTHER (City).
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