USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 42
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2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
(If nonresident, give city or town and State)
INTERVAL
BETWEEN
ONSET AND
DEATH
3 days.
12
91
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT SERVICE NUMBER
· POV 271962 CM
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.
DRM R-302
X 1
PLACE OF DEATH
Middlesex (County) Cambridge
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
Cambridge
(City or Town making this return)
1669 11
Registered No.
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
Mabollo Alice Reinhard
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
191 Somerset Avenue
(if so specify WAR Winthrop, Mass. St
(a) Residence. No.
(Usual place of abode)
2
75
(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
November 25, 1962
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
ROV ...
23.
NOV.
19
V
I last saw h.
CHlive on
NOT. 25,
death is said to
have occurred on the date stated above, at
5:15A
11 If married, widowed, or divorced
HUSBAND of
Herbert
maiden namejaf wife in full)
(or) WIFE of
Tears .
20
Months.
Dayz
If under 24 hours
Hours ......
.Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most working life)
14 Industry
or Business:
Own Home
011-05-
-74.83
15 Social Security No ..
boston
16 BIRTHPLACE (City)
(State or country)
FEss chusetts
17 NAME OF
FATHER
James Dyce
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Scotland
19 MAIDEN NAME
OF MOTHER
Jennie Anderson
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
Herbort F. Reinhard
DATE OF BURIAL
November 28,
62
19
7 NAME OF
Alfred B, Marsh
FUNERAL DIRECTOR
174 Winthrop St. Winthrop
ADDRESS
Received and filed
DEC 6 - 1962
.19.
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Respiratory Deficiency
(a)
Due To Peritonitis
(b)
Due To Perforated Poptic Ulcer (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
yes
What test confirmed diagnosis ?
autopsy
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
eugene Guralnick
M. D.
5 Bay State Rd.
(Address)
Date
11-26
62
Boston
19
Woodlawn Crematory Everett, Mass 6
PARENTS
21 Informant
(Address)
191 Somerset Avc. Winthrop
A TRUE COPY
Phoneas privil veertienich
ATTEST :
(Registrar of City or Town where death occurred)
DATE FILED Nov. 27, 19 62
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER KIDBUN - THIS IS A PERMANENT RECORD
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
50M - 10-61-931673
19 62
.........
INTERVAL
BETWEEN
ONSET AND
DEATH
34hrs
(Husband's name in full)
12
82
1
AGE. .
34hrs
6hrs
62
(Was deceased a
U. S. War Veteran,
no
CERTIFICATE OF DEATH
Mount Auburn Hospital No ..
Place of Burial or Cremation
(City or Town)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
THIROJO
DEC - 61962 AM
RI R-301
1
PENSE. No. PLACE OF DEATH SUFFOLK (County) Winthery (City or Town) 73 Ingleside Ave ANNie E. SheA 2 FULL NAME
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
To be filed for burial permit with Board of Health or its Agent.
CERTIFICATE OF DEATH
Registered No.
212
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
f (Was deceased a U. S. War Veteran,
(First Name) (Middle Name)
(Last Name)
(if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
144. LORING
Rd.
St
(If nonresident, gile city or town and State)
months.
.....
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
10 CITIZEN
OF U.S.
YES
NO
II SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
4 I HEREBY CERTIFY,
October 31,, 7962, to November 28,
1962
19
I last saw le ..... alive on
November 27, 1862
... ,
have occurred on the date stated above, at 12:45 P.M.
death is said to
INTERVAL BETWEEN ONSET AND DEATH
12 DATE OF BIRTH
6 weeks 13
74
.Years.
.Months ....
.Days
If under 24 hours
Hours.
Minutes
Due To
(b)
Primary lesion in left lung
Due To (c)
OTHER
SIGNIFICANTPathological fracture left
CONDITIONS
humerus
August 1962
16 Social Security No.
cnb1
EAST Boston
17 BIRTHPLACE (City)
(State or country)
MASS
18 NAME OF
FATHER
Patrick Muller
19 BIRTHPLACE OF
FATHER (City)
South Boston
(State or country)
MASS
20 MAIDEN NAME
OF MOTHER
MARY E. Leahy
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
IRelAnd
22 MARGARET Mc CARthy (Address) 144 LORing RE Winthrop
I HEREBY CERTIFY that a- satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: firequeuss
(Signature of Agent of Board of Health or other) Health Spice
11/30/60
A TRUE COPY ATTEST:
(Registrar)
PARENTS
OAK Grove Place of Burial or Cremation
Medford
(City or Town)
DATE OF BURIAL
Dec
1
1962
7 NAME OF
FUNERAL
OFRedeRick J. MAGRATH
ADDRESS EAST Boston
Received and filed
19
lla If married, widowed, or divorced
(Give maiden name of wife in full)
HUSBAND of
Charles E. SheA
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Metastatic carcinoma of Brain
1 year
14 Usual
Occupation :
House week
(Kind of work done during most of working life)
15 Industry
or Business :
Own Home
Was autopsy performed?
no
What test confirmed diagnosis?
x-ray.
5 Was disease or injury in any way related to occupation of deceased? If so, specify no
John 7. Colluis ML
M. D.
John F. Collins
27 Bennington S
Print off Type Name)
(Address) ..........
Beachmont Date.
e 11-29
. 1962
(Signed)
- Chapter 137, 1954 requires sans to print or the cause
or «of death on hertificates, and PT 48, Acts of equires Physi- to print or type ender signature. C.
STJCTIONS OR AICERTIFICATE
Irgiving E)F DEATH
ot enter n:han one s for each ), b) and (c)
es not mean 0 of dying, s teart failure, 1,'tc. It means en, or compli- hich caused
ilns, if any, have rise to cause (a), gthe under- ause last.
ntions contrib- o'eath but not the terminal ndition given
1-930213
(Official Designation)
(Date of Issue of Permit) K
L
No
Winthrop
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death. .. years. months. days. In place of residence. ..... years ..
3 DATE OF
DEATH
Nov.
28
1962
(Year)
(Month) (Day) /
That I attended deceased from female
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE. DATE OF DISCHARGE RANK, RATING
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.
RECEIVED
TOWA
OF
...
(NIW)
vin
CLERK
5
'
6
T
ROR
NOV 3 01962 FM
PLACE OF DEATH
Suffolk
PENSEI
(County) Winthrop
(City or Town)
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.
Registered No. 215
[(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a U. S. War Veteran, {if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
195
Main Street
St.
(If nonresident, give city or town and State)
4
27
months
.. days. In place of residence.
.years.
months
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
nov.
29
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
7200. 19 33, to 1200 29
1962
I last saw heralive on
120.29, 1962, death is said to
have occurred on the date stated above, at 1:15-2m.
INTERVAL BETWEEN ONSET AND DEATH
400
you
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
denility
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? 120 If so, specify
(Signed)
M. D. Joseph GREGORIE M.D (PRINT OR TYPE SIGNATURE) (Address) 194 Washington aré Date 11/21/67
6 inthrop
Finthrop
Place of Burial or Cremation DATE OF BURIAL
(Sityc or Town)
32
19
7 NAME OF FUNERAL DIRECTOR Howard & Reynolds
ADDRESS
Winthrop, Mass
Received and filed
[33- 1962
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
white
10 SINGLE
(write the word)
MARRIED Married
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
George Duncan
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
27
Years ..
4
Months.
27
.Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
016-24-25536
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Winthrop
17 NAME OF
FATHER
John Tewksbury
18 BIRTHPLACE OF
FATHER (City)
winthrop
(State or country)
liass
19 MAIDEN NAME
OF MOTHER
Caroline Banks
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
21 George Duncan
Informant
(Address) main Street
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Halkla de sereagane (Signature of Agent of Board of Health or other ).
WHealthe Officer
12/3/67
(Official Designation)
(Date of Issue of Permit)
AR-301A 1
STUCTIONS OR AICERTIFICATE
Lgiving EOF DEATH
Jot enter r than one is for each ) b) and (c)
es not mean le: of dying, s heart failure, a,etc. It means ee, or compli- which caused
lims, if any, h'ave rise to eicause (a), n the under- cause last.
sitions contrib- Heath but not the terminal andition given
Chapter 137, 954. requires ens to print or e cause or of death on (tificates, and 48, Acts of quires Physi- print or type der signature.
·6-59-925686
2 FULL NAME
No. Winthrop Community Hospital
Carrie _ (Tewksbury) Duncan
(a) Residence. No.
(Usual place of abode )
Length of stay: In place of death.
.. years.
1
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
myocardial Heart
(a)
Disease
Due To arteriosclerosis (b)
Om HOME
PARENTS
1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
. . !
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
DEC 3 1962 AM
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.
O.M R-303
d'or burial permit Eard of Health of's Agent.
PLACE OF DEATH
SUFFOLK
(County) WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
214
55 Fremont St., Winthrop No. LAURA JEAN VALLENCOURT
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
2 FULL NAME
(First Name)
(Middle Name)
(Last Name)
( If deceased is a married, widowed or divorced woman, give also maiden name.)
55 Fremont St., Winthrop
.St.
(If nonresident, give city or town and State)
Length of stay :
In place of death.
years.
........ months.
days. In place of residence.
2
.years
... months .........
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Female
10 COLOR
White
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word )
Single
12 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
13 DATE OF BIRTH
JUNE18 1960
5 Accident, suicide, or homicide (specify)
.Accident
Date and hour of injury
November 30,
19
62
IF ACCIDENTAL, was injury causally related to the death ?
Yes
Where did
Winthrop, Massachusetts
Injury occur ?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or public place ?
.....
(Specify type of place)
Manner of Inhalation of smoke from
Injury
Nature of
(How did injury occur ?)
Injury
accidental ..... conflagration
While at work ?
Was ausosy performed ?
Ye3
6 Was disease or injury in any way related to peruurion of deceased?
(Signed
Michael A. Luongo; D.
M. D.
Boston
12/1 ,62
(Address)
Date
19
7 winthrop
Winthrop Mass
Place of Burial, or Cremation. (City or Town) 62
DATE OF BURIAL Dec .. 3
8 NAME OF
FUNERAL DIRECTOR
Ernest P Caggiano
ADDRESS
147 Winthrop St
Winthrop
Received and filed 19
PARENTS
NAME O
FATHER"
Wilfred Vaillancourt
20 BIRTHPLACE OF
FATHER (City)
(State or country)
Maine
Old Town
olli
21 MAIDEN NAME Edna Turner OF MOTHER
22 BIRTHPLACE OF
Saugus
MOTHER (City)
(State or country)
Mass
Thomas Turn
23
Informant
(Address)
54 Buchanan 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) Thatthe M ficere
12/3/69
(Official Designation)
(Date of Issue of Permit)
A TRUE RUE COPY ATTEST:
(Registrar)
A
ARTIONE OF DEATH ON DEATH CERTIFICATES
! ' IN. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of MUAH MITH AKTION
of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF
§§ 44-48.
50M-9-61-931348
EC 3- 1962
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
3 DATE OF
DEATH
November
30,
1962
(Month)
(Day)
(Year)
4 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.) Smoke inhalation with carbon monoxide poisoning
14 AGE 2
Years .....
........ Monthe ............ Days
If under 24 hours Hours Minutes
15 Usual
Occupation
(Kind ofwork done during most of working life)
16 Industry
17 Social Security No.
18 BIRTHPLACE (City)
(State or country)
Boston
Mass
מר
X 1
(Vaillancourt)
PHYSICIAN - IMPORTANT
[(Was deceased a
¿U. S. War Veteran,
No
(if so specify WAR)
(a) Residence. No.
(Usual place of abode)
2
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
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 unrelated to any form of injury. DEC 3. 1962 AM
(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 poison) , 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
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
SEP 7 1962
NORTH CAROLINA STATE BOARD OF HEALTH OFFICE OF VITAL STATISTICS CERTIFICATE OF DEATH
·H215
25057
TREGISTRATION
DISTRICT NO ..
17.00
REGISTRAR'S CERTIFICATE NO.
1. PLACE OF DEATH
& COUNTY
Richmond
b. TOWNSHIP
Varks Creek
e. LENGTH OF
STAY (in 1a)
2. USUAL RESIDENCE (Where deceased lived. If institution: residence before admission)
b. COUNTY
Suffolk
d. CITY
OR
TOWN Hamlet
Is Place of Death Within City
Limita?
NO
e. CITY
OR
TOWN Winthrop
In City Limits?
NO
On a Farm!
.. FULL NAME OF (If not in hospital or institution, give street address or location)
HOSPITAL OR
INSTITUTION Highway 381, 2\'1. E-of Hamlet
d. STREET
ADDRESS
or R. F. D. NO.
398 Shirley St.
3. NAME OF
DECEASED
(Type or Print)
First
James
Middle
Peter
Last Brannan
Month
4. DATE
OF
Day
DEATH Aug. 15, 1962
Year
5. SEX
Male
6. COLOR OR RACE
Cau
7. MARRIED
WIDOWED
NEVER MARRIED
DIVORCED
8. DATE OF BIRTH
11 Apr. 1939
9. AGE (In years last
birthday)
23
IF UNDER 1 YEAR! Months Days
Hours
Min.
100. USUAL OCCUPATION (Give kind of work
done during most of working life, even if retired)
Officer
10b. KIND OF BUSINESS OR INDUSTRY
U.S. Army
11. BIRTHPLACE (State or foreign country)
Winthrop, Mass,
12. CITIZEN OF WHAT COUNTRY! USA
13. FATHER'S NAME
James Norman Brannan
14. MOTHER'S MAIDEN NAME
Unknown
NAME OF HUSBAND OR WIFE
15. WAS DECEASED EVER IN U. S. ARMED FORCES?| 16. SOCIAL SECURITY NO. | 17. INFORMANT'S NAME AND ADDRESS
f yga give war or daten of service)
(Yes. po, or unknowgov 61 to present
01-030-9307
'Army Records
18. CAUSE OF DEATH-ENTER ONLY ONE CAUSE PER LINE FOR (a), (b) and (c).
PART I. DEATH WAS CAUSED BY:
IMMEDIATE CAUSE (a)
ssime 3rd Deque Burns
ANTECEDENT CAUSES-Conditions, if any, which gave rise to above couse (a), stating the underlying cause last.
DUE TO (b). Helicopter accident
DUE TO (c)
PART 11. OTHER SIGNIFICANT CONDITIONS CONTRIBUTINO TO DEATH BUT NOT BELATED TO TERMINAL DIARASE CONDITION GIVEN IN PART I (a) 860X
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