USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 12
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E. Boston,
8
FULL
NAME
Ralph Imbrici
St.
FETAL DEATH
EXTRACTS OF CERTAIN SECTIONS OF TOWi
OF CHAPTER, 46 AS AMENDED OR ADDED BY CHAPTER 48. 1. ACTS OF 1960. IFFI- FLERE
Section 2A. "Examination of records and returns of illegitimate.births, or abnormal sex births, or fetal deaths, ... shall not be permitted except ... ".
6
Section 9A. When a child As porn 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.
RM R-302
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town THIS IS A PERMANENT RECORD
PLACE OF DEATH
Essex
(County)
Danvers
(City or Town)
No.
Danvers State Hospital, Hathorne
S(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
William H. Frizzell
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
56 Main
(Usual place of abode)
2
10
18
Length of stay: In place of death.
.years ....
month
days. In place of residence .......... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
March
19,
1963
(Month)
(Day)
(Year)
I HEREBY CERTIFY,
April 30,
61
). 19 ..
That I attended deceased
March 19.
19
63
I last saw h.mluve on
March 19
6, death is said to
have occurred on the date stated above, at
m.
INTERVAL BETWEEN ONSET AND
(a)
...
Arteriosclerotic heart disease (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 ? If so, specify
Willard M Hausman
(Signed)
Willard M
Hausman
M. D.
(Address)
Hathorne, Mass.
Date.
3/20/
1. 63
19.
Winthrop Cemetery, Winthrop
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
March 22,
63
19.
7 NAME OF
FUNERAL DIRECTOR
Maurice Kirby
ADDRESS
Winthrop,
Mass.
Received and filed
APR 4 1963
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED married
UNKNOWN
11 If married, wModlinieceReed HUSBAND of
(or) WIFE of.
(Husband's name in full)
12
80
7
28
If under 24 hours
Hours ........ Minutes
Steamfitter
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
Not Determined
15 Social Security No ..
Unknown
16 BIRTHPLACE (City)
(State or country}
Caneda
17 NAME OF
FATHER
David Frizzell
PARENTS
18 BIRTHPLACE OF
Unknown
FATHER (City).
(State or country)
Canada
19 MAIDEN NAME
OF MOTHER
Emily Oakes
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Paris
France
Mary F. Sheehan
21 Informant
(Address)
Hathorne, Mass.
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
March .... 21,
1963
TVRV
1
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF TEM TONIE CERTIFICATE OF DEATH
Danvers
(City or Town making this return)
Registered No.
56
(Was deceased a
U. S. War Veteran,
No
Winthrop,
(if so specify WAR, .. Mass.
St
(If nonresident, give city or town and State)
(write the word)
male
to
3:30a
(Give maiden name of wife in full)
AGE
Years.
Months.
Dayı
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Bronchopneumonia (Right SidePeATH
50M . 10.61.931673
2 FULL NAME
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
OF TOW
SERVICE NUMBER
OFFICE.
3
LERK
6
THROR
APR :41963 AM
FORM R-301
d for burial permit Board of Health its Agent. STRUCTIONS FOR AL CERTIFICATE
T OR TYPE : OR CAUSES 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
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
m.C.
PLACE OF DEATH
Suffolk ..... (County)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
(City or Town making this return) .....
1
Winthrop
(City or Town)
No
42 Pearl Ave. , Winthrop, Mass. St. ( give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
42 Pearl Ave.
(a) Residence. No ...
(Usual place of abode)
Length of stay: In place of death ......... 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
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word) married
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
....
1 en.
19
50
.. , to ... March 24 19 63
I last saw himlive on
MARCH 21, 1963
death is said to
have occurred on the date stated above, at
livs A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Coronary Occlusi
1 hour.
18 months
13 Usual
Occupation :
salesman
(Kind of work done during most working life)
14 Industry Sundries & peper
or Business :
O11-09-5893
15 Social Security No
16 BIRTHPLACE (Ciposton (State or country) E
17 NAME OF FATHERRalph Turransky
18 BIRTHPLACE OF FATHER (City) (State or country)
Russia
19 MAIDEN NAME OF MOTHERAnnie Finn
20 BIRTHPLACE OF MOTHER (City). (State or country)
Russia
wife Ruth Turrensky
21 Informant
(Address)
42 Pearl Ave Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was ,fuled with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other) Health Effects
march 2.5 1963
(Official Designation)
(Date of Issue of Permit)
-62-932382
A TRUE COPY ATTEST:
3yrs.
Was autopsy performed ?
NO
What test confirmed diagnosis ?
CLINICAL
5 Was disease or injury in any way related to occupation of deceased ?No If so, specify
(Signature)
Charles Liberman.
M. D.
CHARLES
LIBERMAN
PARENTS
(Address)
WINTHROP, MASS Date.
Print or Type Name)
3/24/1963
Sharon Memorial Park Sharon 6
Place of Burial or Cremation
24 March
.. 19
(City or Town) 63
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Benj. F. Solomon
ADDRESS
420 Harvard St. Brookline
Received and filed
MAR 25 1963
19
(Registrar)
11 If married, widowed, or divorce HUSBAND of Ruth Epstein
(or) WIFE of
(Husband's name in full)
12
AGE
52
.Years.
Months .....
.Days
If under 24 hours
.. Hours ........ Minutes
Hypertensive. Coronary
(b)
ARTERY Ht. Disease.
Due To
(c)
OTHER
DIABETES MELLITUS.
CONDITIONS
24 1963
Winthrop
St
(Was deceased a U. S. War Veteran, (if so specify WAR)
no
[(If death occurred in a hospital or institution,
Abraham
Harold Turransky
STANDARD CERTIFICATE OF DEATH
Registered No. .......... .......
(If nonresident, give city or town and State)
3 DATE OF
DEATH
MARCH
INTERVAL
BETWEEN
ONSET AND
DEATH
(Give maiden name of wife in full)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TOO
THE
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance 00 0e2 51963 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 froin 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)
The Commonwealth of Massachusetts KEVIN H. WHITE 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. 58
f(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
2 FULL NAME
Eleanor L. Waggett
(McGurn)
(Was deceased a
U. S. War Veteran,
[if so specify WAR)
No
95 Main Street, Winthrop
St.
(If nonresident, give city or town and State)
12
Length of stay: In place of death .years months .. days. In place of residence. .12 .. years
.... months ............ days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
March
25
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
19
.. , to.
19
That I attended deceased from
I last saw h ........ alive on
19 ..
death is said to
have occurred on the date stated above, at
3:45 P. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Death presumably due to
(a)
INTERVAL BETWEEN ONSET AND DEATH
Due Tonatural CAUSES, namely (b)
generalized and coronary
Due To artery arteriosclerosis .! (c) complicated by diabetes
OTHER SIGNIFICANT CONDITIONS viellitus of yours duration
Was autopsy performed?
Winthrop Board of Health
What test confirmed diagnosis?
Charles Liberaway MM
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
CHARLES LIBERMAN
(Print or Type Name)
(Address) WINTHROP Date. 3126/ 1965
Holyhood Cemetery, Brookline
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
March ... 28th
1963
7 NAME OF
FUNERAL DIRECTOR
Richard C. Kirby, Inc
ADDRESS917 Bennington St. ,E.Boston
Received and filed
MAR 26 1963
19
(Signature of Agent of Board of Health or other)
A).auch.26,1963
(Official Designation)
(Date of Issue of Permit)
T V.B.V
TRUCTIONS FOR L CERTIFICATE
giving : OF DEATH not enter e than one e for each , (b) and (c)
does not mean de of dying, heart failure, , etc. It means ase, or compli- which caused
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not to the terminal condition given HI.C.
e :- Chapter 137. of 1954 requires cians to print or the cause or % of death on certificates, and :er 48, Acts of requires Physi- to print or type under signature.
-61-930213
A TRUE COPY ATTEST:
(Registrar)
PARENTS
18 NAME OF
FATHER
Owen McGurn
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
20 MAIDEN NAME OF MOTHER Mary Morrow
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
22
Miss Catherine B. Waggett-dau.
Informan
95 Main 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: Kaiph E
Boston
17 BIRTHPLACE (City) (State or country) Mass.
If under 24 hours Hours. ...... .Minutes
14 Usual
Occupation :
.....
Housewife
(Kind of work done during most of working life)
15 Industry
or Business:
At home
16 Social Security No.
None
YES NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Andrew J.
Waggett
(Husband's name in full)
12 DATE OF BIRTH
Sept.6,1870
13
AGE.
9.2Years ..
6
Months.
.19 ... Days
9 COLOR
White
10 CITIZEN
OF U.S.
8 SEX
Female
(Last Name)
(First Name) ( Middle Name) (If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. (Usual place of abode)
PHYSICIAN - IMPORTANT
95 Main Street, Winthrop
No.
M R-301 1
M. D.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
MOI
OF
THROI
RULES OF PRACTICE MAR 2 61963 AM
The fulfillment of the purpose of these laws calls for the observance 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 froin 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.
ORM R-301
for burial permit bard of Health its Agent. TRUCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH not enter than one e for each (b) and (c)
does not mean de of dying, heart failure, etc. It means ise, or compli- which caused
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not o the terminal condition given
C
PLACE OF DEATH
Suffolk (County)
.OVIETEM
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No. 59
[(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)
(a)
Residence. No ...
2 Washington Terrace
St
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death years months ........ days. In place of residence 87 years 2 months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED Married
WIDOWED
DIVORCED
UNKNOWN
Male
White
11 If married, widowed, or-divorced
HUSBAND of
Alice Abbott Munday
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE81 .. Years .. 2 ...... Months2.0.
.Days
If under 24 hours
Hours ........ Minutes
reared office Mgr
(Kind of work done during most working life)
14 Industry
or Business :
General Electric Co.
15 Social Security No ...
01-205-3423-A
16 BIRTHPLACE (City) .....
winthrop
(State or country)
massachusetts
17 NAME OF
FATHER
John Wood ry Davison
18 BIRTHPLACE OF
FATHER (City)
Gloucester
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTIIER
Tovicy White
20 BIRTHPLACE OF
MOTHER (City)
Plymouth
(State or country)
Vermont
21 Informant
Mrs .... Alice Davison
( Address) 2 Washington Terrace, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: faith 18 Serianni (3)
(Signature of Agent of Board of Health or other)
Health Officie
1/2011, 1963
....
(Registrar )| (Official Designation)
(Date of Issue of Permit)
TYPV
A TRUE COPY ATTEST:
3 DATE OF
March 29
1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Sept ......... 1 ..... , 19.6.0 ..... , to.March ..... 29
19 .. 6.3
I last saw KLMlive on March ..... 2.7.
16.3 .. , death is said to
have occurred on the date stated above, at
5:30am
n.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
heart
disease
(a) .Arteriosclerotic
3 yrs
Due To
Generalized
(b)
arteriosclerosis
5 yrs
(c)
Due To
Parkinsons disease
5 yrs
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
no
What test confirmed diagnosis? clinical & lab
5 Was disease or injury in any way related to occupation of deceased ..... If so, specify
(Signature)
M. Traunstein
M. D. M. Traunstein, Jr. V.M. D.
(Print or Type Name)
(Address)
73 Bartlett Rd
3-30
163
Winthrop Cemetery Winthrop, Lass. 6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
alfred th March
ADDRESS
174 Wintifop Street, Winthrop
Received and filed
APR 1 1963
19
62-932382
I
Winthrop (City or Town)
No. Mount Convalescent Home, Inc.
Roland Erle Davison
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(City or Town making this return)
PARENTS
April 1,1963
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RECE VED
RANK, RATING
TOM
ORGANIZATION AND OUTFIT
SERVICE NUMBER
-1
6
1ª
RULES OF PRACTICE
YTHROR
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 a's those of pensons to whom they have given bedside care during a lan illness from disease fun- 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 froin 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.
M R-303
1
(County) WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
(City or Town making this return) .....
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Registered No.
60
304 Pleasant St.,
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
No.
2 FULL NAME
(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.) 304 Pleasant St., Winthrop
(a) Residence. No.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of deathyears months days. In place of residence 35 years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
March
29,
1963
9 SEX
10 COLOR
white
11 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
(write the word)
married
(Month)
(Day)
(Year)
4I 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.)
12 If married, widowed, or divorced HUSBAND of Effie.
ae Poolen
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
5 Accident, suicide, or homicide (specify)
Date and hour of injury
retiredUsalerk 19.
.....
(Kind of work done during most of working life)
15 Industry
Business : .....
(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
Injury
(How did injury occur ?)
Nature of Injury
While at work? Was autopsy performed ...
6 Was disease of injury in any way related to occupation of deceased ?
(Signed)
Michael
Luongo ,M.D.
Boston ( Print or Type Name)
Date 3/301963
7 Grove Cem tery Fre port, Maine
l'lace of Burial or Cremation. (City or Town)
8 NAME OF
FUNERAL DIRECTOR
DATE OF BURIAL April 3 1963 alfred B. March
ADDRESS 1.74Winthrop St.Winthrop
Received and filed
19
A TRUE COPY ATTEST:
(Registrar)
PARENTS
18 NAME OF FATHER George Sherman O'Malley
Lowell 19 BIRTHPLACE OF FATHER (City) (State or country) Massachusetts
20 MAIDEN NAME OF MOTHER Georgia Anna Murch
21 BIRTHPLACE OF
M. D. MOTHER (City) (State or country)
Maine
22 Informant Urs. Carle F. O'malley
(Address)
304 Pleasant St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial ør transit permit was issued : Mass. Parphil Vivienne (B)
ASignature of Agent of Board of Health or.other) Health Effects
(Official Designation (Date of Issue of Permit) V
· If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. §§ 44-48.
100M - 3-62-932695
PLACE OF DEATH
SUFFOLK
I for burial permit oard of Health its Agent.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of 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
ACUTE MYOCARDIAL INFARCTION
13 AGE 59 Years ........... .. Months. KOD ....... Days
If under 24 hours Hours Minutes
IF ACCIDENTAL, was injury causally related to the death ? Where did Injury occur ?
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