USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 32
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Y
PLACE OF DEATH
SUFFOLK (County) BOSTON (City or Town)
........
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
160 WUT - OF - TOWN To be filed for bur'a: permit with Board of Health or its A. en'.
05597 Registered No.
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Mf deceased is a married, widowed or divorced woman, give afso maiden name.)
71 GROVERS AVE
St. WINTHROP MASS
(If nonresident, give city or town and State)
Length of stay : In place of death ............. years .............. months ...
2
.days. In place of residence
3
........ years ...... months ....
..... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATII
6
7
1961
(Month)
(Day)
(Year)
4I HERENY
6/5
CERTIF
That I attended deceased from
19
f last saw h .. .. Lalive on ...
6/7
12.45. ... , death is said to
have occurred on the date stated above, at
6
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Toxic SHOCK
INTERVAL BETWEEN ONSET AND DEATH
f1 IF STILLBORN, enter that fact here.
12
AGE ....... Years ..... Months. Days
If under 24 hours
Hours ....
Minutes
13 Usual
Occupation :
BRUSHER
(Kind of work done during most of working life)
14 Industry
or Business
MEN'SCLOTHING FACTORY
15 Social Security No.
021-24-7772
=
16 BIRTHPLACE (City)
(State or country)
MASS.
17 NAME OF
FATHER
VINCENZO CORSANO
18 BIRTHPLACE OF
FATHER (City)
-
(State or country)
ITALY
19 MAIDEN NAME
OF MOTHER
ANNA DELLEA
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
ITALY
21 ADOLPHE D'AMICOJA.
(Address BERKSHIRE AVE SOUTHVIER
7 NAME OF FUNERAL DIRECTOSPIETROKVALLA ADDRESS HENRY ST, EAST BOSTON
Received And filed .......
AUN 19 1961
(Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of death was gled with me BEFORE the/burial of transit permit was issued: Daniel M Damora jl (Signature of Went of Board of Health or other) 2445 6/9/6/
(Official Designation) (Date of Issue of Permit)
.
1
Y
C
R-301A -
CTIONS OR ERTIFICATE iving P DEATH t enter han one for each ) and (c) s not meo. of dying, cart failure. c. It means or compli- rick caused Ca s, il/amy. ve rise to Iuse (a), ke rader. use lest. hapter 137. 4. requires to print or cause or death on hestes, and . Acts of res Physi- int or type · signature. Only cause of death Dr. wasVable to give this office. jd. oms contrib- ath but not the terminal dition given
25 1961
59-926662
8 SEX
FEMALE WHITE.
9 COLOR
10 SINGLE
.. (write the word)
MARRIER,
of DIVORCED
foa ff married, widowed, or divorced
HUSBAND of
(Give maiden name ol wife in lull)
(or) WIFE of
ADOLPHE. D'AMICO
(Husband's name in full)
Due To
SEPTICEMIA
(b)
Due To POST ABDOMINAL SURGERY
(c)
Abdominal adhesions.
OTHER
SIGNIFICANT
Suspension of Vaging.
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
yes
5 Was disease or injury in any way related to occupation of deccased? If so, specify .......******
(Signed)
Time Today, M.D
M. D.
PIERRE TORBEY
OPRINT OR, TYPE SIGNATURES
(Address)NEW ENGLAND HER Ste 6/8
1961
6 ST.766ELS
BOSTON
(City or Town)
Place of Burial or Cremation
DATE OF NURIAL
JUNE 12
1961
PARENTS
CERTIFICATE OF DEATH
NEW ENGLAND HOSPITAL
No.
JEAN (CORSANO) D'AMICO
[(Was deceased a
U. S. War Veteran,
(if so specily WAR)
NO
(a) Residence. No. (Usual place of abode)
BOSTON
A TRUE COPY ATTESTI Tuiles & Mackie City Repristrar
SEP 22 51961 AM
PLACE OF DEATH
SUFFOLK
(County)
BOSTON
(City or Town)
Massachusetts General Hospital BAKER MEMORIAL
No.
Cora Ella C. Lent
St. { give Its NAME Instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
55 Sargent Street
Winthrop, Massachusetts
(Usual piace of zoode)
Length of stay: in place of death ............ years ...
months.
days. In place of residence.
4.5years.
... months ..
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
MARRIED
WHOWE.D
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of ...
(Give maiden name of wife In full)
(or) WIFE of
John Israel. Lent
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE .... 85.Yearf.
1
.Months.
7_Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
housework
(Kind of work done during most of working life)
14 Industry
or Business :
avm home
15 Social Security No.
012-03-3977-D.
East Boston
16 BIRTIIPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
William C.Peters
18 BIRTHPLACE OF
FATHER (City)
East Boston
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Sarah Frances Hammond
20 BIRTHPLACE OF
MOTHER (City)
East Boston
(State or country)
Massachusetts
121 Miss Dorothy M Lent
Informant
(Address)
55 Sargent St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death wu fled with me BEFORE the bartel or transit permit was lesmed: Mass. Danilo
Signature of Agent of Board of Health or other) 3526 6/15761
(Official Designation) (Date of Issue of Permit)
PARENTS
6
Woodlawn Cemetery Everett Mass
l'lace of Burial or Cremation
(City of Town)
DATE OF BURIAL June 15, 1961
7 NAME OF
FUNERAL DIRECTOR
acked B. Mars
ADDRESS
174 Winthrop St. Winthrop,
Rortyld jd fled JIN.16. 1961 Charles H Macke (Registrar)
6 days
Due To (c)
CARCINOMA OF BREAST
20 yrs
Was autopsy performed?
Yos
What test confirmed diagnosis?
Autopsy;
S Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
caillou
M. D
Charles.L. Cley, M. D.
(PRINT OR TYPE SIGNATURE)
(Address) Ain't. Die., Hans. Gen'l. Herp.
Date. June ..... 12.19 ... 61
R-301A 1
CTIONS a ERTIFICATE
ving F DEATH
tenter an one or each ) and (c)
-- of dying, ort failure. c. It means
3, if any. De rise to
he under-
ons contrib- etk but not the termined dition riven .C.
54%.
Chapter 137, 954. requires is to print or : cause or of death on tificates, and 48, Acta of viren Physi- print or type er signature.
İresten · only Ink. 25 1961
28145
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
OUT - OF - TOWN To be filed for burisi permit with Board of Hesith or ita Agent.
STANDARD CERTIFICATE OF DEATH
Registered No 1.220-
[(If death occurred in a hospital or Institution,
((Was decessed a U. S. War Veteran.
lif so specify WAR)
No.
3 DATE OF
DEATH
Juno ..... 12 ...... 1961
(Month)
(1)ay)
(Year)
4| HEREMY CERTIFY . ThatWE attended deceased from
19.
61
April .. 14 ...... 1961, to ..
June 12,
" last saw JOralive on
June .. 12.,., 1961 .. , death is said to
have occurred on the date stated above, at ..... 3.5.5 ..... p.m.
INTERVAL
BETWEEN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) EXSANGUINATION
ONSET AND
DEATH
days
(b)
Due TO DUODENAL ULCERS, BLEEDING
OTHER
SIGNIFICANT
CONDITIONS
RECURRENT
10 SINGLE
mise the word),
Widowed
( If nonresident, give city or town and State)
A TRUE COPY ATTEST: Charles it Mackie City Registrar
SEP 2 51961 AM
M R-303 B
-
Boston (City or Town)
The Commonwealth of Casoarquestts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent. 05722
Registered No.
Ward { give its NAME instead of street and number) No. 818 Harrison Avenue Si.
2 FULL NAME Abraham A. Hercules
(If dereased is a married, widowed or divorced woman, give also maiden name.)
PHYSICIAN -- IMPORTANT
(Was deceased a
U. S. War Veterar ..
if so specify WAR)
no
....
(a) Residence. No. . 28L ... River Road,
.Ward. ... Winthrop. .. Mass.
(Usual place of abode)
(if nonresident, give city or town and State)
Length of residence in city or town where death occurred yrs.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
COLOR
white
5 SINGLE
MARRIED
WIDOWED Single
or DIVORCED
Sa If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN. enter that fact here.
8
AGE. 76 .Years
Months
Days
If less than 1 day
Hours
.Minutes
Usual
9 Occupation:
Salesman
(retired)
Industry
10
or Business:
Cigar.
Social Security No. ...
010-1/1-1765
Boston,,
12 BIRTHPLACE (City) (State or country) Mass
13
NAME OF
FATHER
Nathan Hercules
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Germany
15 MAIDEN NAME
OF MOTHER
Erma Mehlinger
16
BIRTHPLACE OF
MOTHER (City)
Wachenheim, Rhine Bavaria,
(State or country)
Germany
17 Informant.Morton ... Fcinberg
Relalion, if any
(Address) 95 Jechington Street, Dorchester.
I HEREBY AFPTIFY that a satisfactory standard certificate of death was Nød with mp 51.1 01;K the burial or tounsit permit was issued:
(Signature of Agent of Board of health or other
5.10. . 115 16-
(() "cial I) .. (L'ate of Issue of Porini!)
18
DATE OP
DEATH
June 13 1961
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY that I have investigated the death of the person · above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.)
Coronary
Occlusion
Collapsed au
Side walk
20 IN WHAT CIPY OR TOWN
WAS INJURY SUSTAINED ?.
Wheels
(Signed)
.. M. D.
6-14-61
(Address)
25 .... Shattuck. St.
Date
21
PLACE OP BURIAL.
Moses, Mendelsohn.
CREMATION OR REMOVAL ... .. West Roxbury.
(Cemetery)
(City or towa)
DATE OP BURIAL
June ... 16,
.1961
22
NAME OF
UNDERTAKER
Benjamin F.Solomon
420 Harvard Street, Brookline
ADDRESS
JUN 16.1961
19
Charles & Mackie
(Registrar)
PARENTS of Death. See reverse side for extracts from the laws relativo to the return of certificates of death. DEATH In plain terms, so that it may be properly classified under the International Clus. ication of Causes If deceased was a U. S. War Veteran, G.L. Chap. 45, Section 10, requires physicians to insert a recital to that efect Information should be carsis y supplied. . ILALEA. s. o. C ... ORLINER OF 11
SM-3-56-922107
m.C. 20.1
25 1961
PLACE OF DEATH
Suffolk (County)
(write the word)
1.
Nephew
OUT - OF - TOWN
1(If death occurred in a hospital or institution.
A TRUE COPY ATTEST:
un ho H. Mackie City Registrar
.
SEP 251961 AM
R-301A 1
UCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
es not mean : of dying, heart failure, etc. It means e, or compli- which caused
ns, if any, ave rise to cause (a), the under- cause last.
tions contrib- leath but not the terminal ndition given 11C
PLACE OF DEATH
Suffolk (County)
INSEPFTE
Winthrop (City or Town}
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Registered No.
142
§(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
Katherine McGillicuddy
( First Name)
(Middle Name)
(Last Name)
[(Was deceased a
U. S. War Veteran,
[if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
39 Pico Avenue
St.
(If nonresident, give city or town and State)
Length of stay: In place of death ..
......
.years ..
.months.
.days. In place of residence.4.8.
.. years
.months .......
.days.
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE
(write the word)
MARRIED
WIDOWEDSingle
or DIVORCED
4 I HEREBY CERTIFY,
2/14
19.
61
to ...
19
61
That I attended deceased from
9/1
I last saw her.alive on
4/1
1961
death is said to
have occurred on the date stated above, at
7A
m.
INTERVAL BETWEEN ONSET AND DEATH
Due To
BRONCHO.
.
(b)
PNEUMONIA
2 DAYS
KMO.
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
0
What test confirmed diagnosis?
XBAX-BIOPSY
0
(Signed)
Thed o' Began
M. D
FRED O' REC
SIGAN
11.0
PRINT OR TYPE SIGNATURE) 113PLEASANTLY .. Date 9/1 1961
(Address)
WINTHROP
6
Winthrop Cemetery
Winthrop
Place of Burial or Cremation
(City or Town)-
DATE OF BURIAL
September 5
19
61
7 NAME OF
FUNERAL
DIRECTOR
Arthur J .O.Maley
ADDRESS Winthrop Mass
Received and filed
SEP 1 1961
19
(Registrar)
PARENTS
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country)
Mass
19 MAIDEN NAME
OF MOTHERMary A. Harron
20 BIRTHPLACE OF MOTHER (City) Everett (State or country) Mass
21
Nancy McGillicuddy
Informant
(Address)
39 Pico Ave., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or ,transit permit was issued: Raucht foram (Signature of Agent of Board of Health or other)
9/1/61
(Official Designation)
(Date of Issue of Permit)
L 1
1
11 IF STILLBORN, enter that fact here.
12
48
AGE
Years.
Months ....
Days
If under 24 hours
Hours ....
Minutes
13 Usual
Occupation :
Operator
(Kind of work done during most of working life)
14 Industry
or Business:
Telephone
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Winthrop
Mass
17 NAME OF
FATHER
William McGillicuddy
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
3 DATE OF
DEATH
September 1, 1961
(Month)
(Day)
(Year)
8 SEX
Female
9 COLOR
White
MEDICAL CERTIFICATE OF DEATH
(Usual place of abode)
No. 39 Pico Avenue
-928145
1.0
Due To
CARCINOMA
(c)
OF
LUNG.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE. " ;
DATE OF DISCHARGE
RANK, RATING CSEP -1961 PM
ORGANIZATION AND OUTFIT
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.
PLACE OF DEATH
SUFFOLK (County) WINTHROP (City or Town)
Prostor 12-9-61
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
WINTHROP CONVALESCENT HOME
give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a
{U. S. War Veteran,
{if so specify WAR)
NO
St EAST BOSTON, MASS (If nonresident, give city or town and State) 2 .. years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
SEPT.
6,
1961
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
~ That I attended deceased from
JAN -8,
19 .... , to ....
SEPT.
L
19.6/
I last saw heRalive on
19.6/, death is said to
have occurred on the date stated above, at ....
2:30 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) CARDIAC DECOMPENSATION
2 DAYS
Due To ARTFRIOSCLEROTIC (b) .. . HEART DISEASE
10 YRS.
Due To (c)
OTHERLEFTCEREBRAL HEMORRHAGE I MONTY SIGNIFICANT CONDITIONS PARKINSON'S DISEASE 15YRS
Was autopsy performed ?
NO
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed) an. Caplan M. D. A. N. CAPLAN M.D. (PRINT OR TYPE SIGNATURE)
(Address) 186 PRINCETONSTE. B Date.
9-6- 19.61
6 HOLY CROSS Place of Burial or Cremation (City or Town) DATE OF BURIAL SEPT. 9 1961
7 NAME OF DIPIETROXVAZZA ADDRESS HENRY STEAST BOSTON
Received and filed
SEP 8 -1961
19
(Registrar)
PARENTS
16 BIRTHPLACE (City) (State or country)
ITALY
17 NAME OF
FATHER
RICCI
18 BIRTHPLACE OF
FATHER (City)
(State or country)
ITALY
19 MAIDEN NAME
OF MOTHER
NOT LEARNED
20 BIRTHPLACE OF MOTHER (City) (State or country) ITALY
21 AUGUSTUS MANGONE Informant 68 FALCONST, EAST BOSTON
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or transit permit was issued: Talkle Jereannex ( Signature of Agent of Board of Health or other) Heath Prices 9/8/1
(Official Designation)
(Date of Issue of Permit)
& hosp
FRANCESCA MANGONE
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
68 FALCON
Length of stay: In place of death ..... .. years.
months.
16
... days.
In place of residence .....
8 SEX
FEMALE WHITE
9 COLOR
(write the word)
10 SINGLE
MARRIED
WIDOWENDO WED
or DIVORCED
10a If married, widowed, or divorced HUSBAND of
(or) WIFE
(Giye maiden name of wife in full) BENJAMIN MANGONE
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
86
Years ....
Months ....
Days
If under 24 hours
Hours.
.Minutes
13 Usual
Occupation :
HOUSEWIFE
(Kind of work done during most of working life)
14 Industry
or Business :
OWN HOME
15 Social Security No. NONE
ons, if any, ave rise to cause (a), the under- cause last.
tions contrib- death but not the terminal ndition given
Chapter 137, 954. requires is to print or : cause or f death on tificates, and 48, Acts of uires Physi- print or type er signature.
-59-925686
821 1.6
R-301A 1
UCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
es not mean e of dying, heart failure, etc. It means e, or compli- which caused
INTERVAL BETWEEN ONSET AND
MALDEN
To be filed for burial permit with Board of Health or its Agent.
Registered No.
(a) Residence. No.
(Usual place of abode)
SEPT 6,
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
TOW
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
63
ERK
RULES OF PRACTICE SEP -81961 FM
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.
X 1 PLACE OF DEATH
SUFFOLK (County) WINTHROP (City or Town)
REVERE 12-2020
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.
165
WINTHROP CONVALESCENT HOMETIL death occurred in a hospital or institution.
give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
CONCETTARIVOIRE
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
14 ARCADIA
REVERE MASS
St.
(If nonresident, give city of town and State)
Length of stay: In place of death .............. years.
.. months.
.days. In place of residence
8
... years ..
... months .......
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Sept
7
1961
(Month)
(Day)
(Year)
8 SEX
FEMALE
9 COLOR
WHITE
10 SINGLE
MARRIED
(write the word)
WIDOWAWIDOWED
or DIVORCED
4 I HEREBY CERTIFY,
Oct. 11
19.00, to
Sept. 7.
1961
I last saw h .. CYalive on
sept
...................... , 19 ......... , death is said to
have occurred on the date stated above, at
1:00 P.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Cerebral Hemorrhage
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
2mths
11 IF STILLBORN, enter that fact here.
12
AGES ... Yearsm
.. Months ...
.Days
....
.. Minutes
Due To
Generalized Arteriosclerosis
.5
(b)
years
Due To
DIABETES Mellitus.
(c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
NO.
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
NO
(Signed) Morris I. Sacks M. D. MORRIS 1, SACKS M.A (PRINT OR TYPE SIGNATURE) (Address) 45 Shirley Ave. 2. Da Sept. 1 19 61
6. FOREST HILLS BOSTON
Place of Burial or Cremation
DATE OF BURIAL
SEPT.
......
(City or Town)
1961
7 NAME OF
DIPIETROLAVAZZA
ADDRESS 1HENRY ST, EAST BOSTON
Received and filed SEP 8 1961 19
(Registrar)
PARENTS
19 MAIDEN NAME
OF MOTHER ANNA LACÍVITA
20 BIRTHPLACE OF MOTHER (City) (State or country) ITALY
TINA LUCEY
21
Informant
(Address)4 ARCADIAST, REVERE
I HEREBY, CERTIFY that a satisfactory standard certificate of death was fled with me BEFORE the burial or transit_permit was issued: Jacka 8. Sercaune 8- (Signature of Agent of Board of Healthy or other)
9/8/6/
(Official Designation)
(Date of Issue of Permit) /
UCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each b) and (c)
es not mean of dying, heart failure, etc. It means , or compli- which caused
ns, if any, ave rise to cause (a), the under- cause last.
tions contrib- leath but not the terminal ndition given
Chapter 137, 954. requires s to print or cause or f death on tificates, and 48, Acts of uires Physi- print or type er signature.
59-925686
13 Usual
Occupation :
HOUSEWIFE
(Kind of work done during most of working life)
14 Industry
or Business :
OWN HOME
15 Social Security No.
028-03-7857
16 BIRTHPLACE (City)
(State or country)
ITALY
17 NAME OF.
FATHERSALVATORE CASSIANI
18 BIRTHPLACE OF
FATHER (City)
(State or country)
ITALY
104+5
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
LAMY
(Give maiden name of wife in full) RIVOIRE
(Husband's name in full)
If under 24 hours
.. Hours ..........
That I attended deceased from
[(Was deceased a
U. S. War Veteran,
lif so specify WAR)
NO
(a) Residence. No.
(Usual place of abode)
Registered No.
R-301A 61 1
19%-6
SPACE FOR ADDITIONAL INFORMATION
RECEIVED
DATE OF ENTERING MILITARY SERVICE
OF TOW.
DATE OF DISCHARGE
11 12
·!
RANK, RATING
SHO
ORGANIZATION AND OUTFIT
SERVICE NUMBER
WIN
NTHROP
SEP -81961 FM
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.
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