Town of Winthrop : Record of Deaths 1963, Part 13

Author: Winthrop (Mass.)
Publication date: 1963
Publisher:
Number of Pages: 574


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 13


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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diy ...... goods ..... wholesale


032-14-5284


Social Security No. ....


Lowell


17 BIRTHPLACE (City) (state or country) Massachusetts


.....


D


Unity


(Address)


PHYSICIAN - IMPORTANT


CARLE W. MALLEY ('O'malley )


male


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


TO !!


SERVICE NUMBER


RULES OF PRACTICE INTHROT


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 nessons to whom they have given bedside care during a last illness from disease unrelated to any form of injury. APR - 21963 PM


(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.)"


M R-301A 1


PLACE OF DEATH


Suffolk (County) WINThrop (City or Town)


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


To be filled for burial permit with Board of Health or its Agent.


No. 37 Bellevue Are-


2 FULL NAME


Stephen D. CASASSA


(If deceased is a/married, widowed or divorced woman, give also maiden name.)


(a) Residence,


No.


37 Bellevue


Are-


St


WINThrop


(If nonresident, give city or town and State)


Length of stay: In place of death. ...... years months days. In place of residence 3 years .months ...... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


MARCH 30 - 1963


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY, That I attended deceased from


, 19


to


19


I last saw h _____ alive on


., 19


, death is said to


have occurred on the date stated above, at


3:45 P. m.


INTERVAL BETWEEN ONSET AND DEATH


11 IF STILLBORN, enter that fact here.


12


AGE 8 4 Y


Years


1 Month: 23 Days


If under 24 hours


Hours ..... Minutes


13 Usual


Occupation :


Retired-


(Kind of work done during most of working life)


14 Industry


or Business:


Basket


DeAlER


15 Social Security No ..


16 BIRTHPLACE (City) BOSTEN


(State or country)


MASS


17 NAME OF


FATHER


MARIO CASASSA


18 BIRTHPLACE OF FATHER (City) (State or country)


ITALY


19 MAIDEN NAME


OF MOTHER


Rose CAvagNaro


20 BIRTHPLACE OF


MOTHER (City).


(State or country)


ITAly


21 MrsEMMA R. Casassa


(Address) 37 Bellevue Ave- WIN


7 NAME OF


ARTHUR S. PORcellA


ADDRESS


826 Lei Thrap Ave Refere


Received and filed APR 1 1963 19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Male


9 COLOR


WHITE


10 SINGLE


(write the word)


MARRIED


WIDOWED


Married


10a If married, widowed, or divorced


HUSBAND of


EMMA R.


SORACCO


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Death due to natural


causes


presumably


Due To


acute coronary


(b)


occlusion hases ion


Due


(c)


history.


Was autopsy performed? What test confirmed diagnosis?


5 Was disease or injury in any way related to occupation of deceased ?


If so, specify


(Signed)


Charles Léhammers M.


(Address)


Winthrop


Date 3/31/1963


WINThrop


6


Place of Burial or Cremation


WINThrop (City or Town)


DATE OF BURIAL


April


2-


1963


PARENTS


Registered No.


[(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).


No


(Usual place of abode)


;TRUCTIONS FOR IL CERTIFICATE


n giving ; OF DEATH not enter e than one se for each , (b) and (c)


daes nat mean de af dying. heart failure, etc. It means ase. ar campli- which caused


ions, if any, gave rise ta cause (a), the under- cause


last.


itians cantrib -- death but wat l'a the terminal canditian given 1


Chapter 137, 1954, requires fans to print or he cause or of death on 'ertificates.


50M-1-58-921876


I 11EREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial- or transit permit was issued: Kaiple da denanni (3) (Signature of Agent of Board of Health or other)


faith Officin


(Official Designation)


(Date of Issue of Permit)


X


OTHER


Winthrop Board of Health


SIGNIFICANT


CONDITIONS


EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE


RETURN OF CERTIFICATES OF DEATH


A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.


A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Chap. 46, Sec. 10.


No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the


death certificate contains a recital, as required by. section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).


Medical examiners shall make examination Hi upon the view of the dead bodies of persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease; or when any person is found dead. . - General Laws, Chap. 38, Sec. 6 , as amended;by Chap., 632, Sec. 4, Acts of 1945.


No undertaker or other persons shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the derk of the town where the body is to be buried or the funeral is to be held. of from a person appointed to have the care of the cemetery or burial ground in which the interment is made.


Chap. 114, Sec. 46, G. L., (Tercentenary Edition).


ES OF PRACTICE THROP,


The fulfillment of the purpose of these laws calls for the observance of the follow- ing rules of practice:


(1) Attending physicians will, certify to such deaths only as those of persons to whom they have given beAsPIRcare fulof glaffillness from disease unrelated to any form of injury.


(2) Board of Health physicians will certify to such deathsonly 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 occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .-- Precise statement of occupation is very import- ant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework. write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING ORGANIZATION AND OUTFIT


SERVICE NUMBER


ORM R-304


PLACE OF DELIVERY No.


Suffolk (County)


ENSE PETT


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)


To be filed for burial permait , with Board of Health or its Agent.


Registered No.


(If death occurred in a hospital or institution, give its NAME instead of street and number)


3 DATE OF


DELIVERY


March 30, 1963 (Month )


(Day)


(Year )


4 SEX


Malex


Female ..... 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


14


MAIDEN NAME


PRESENT NAME


MOTHER Rosemarie Velardo Rosemarie Velardo


9


RESIDENCE, NO.


CITY OR TOWN


STREET


STATE


15 RESIDENCE, NO. CITY OR TOWN


1061 Saratoga St. East Boston


STREET


STATE Mass,


10 COLOR OR


RACE ..


11 AGE AT TIME OF


THIS DELIVERY


(Years)


16 COLOR OR


RACE.


W


17 AGE AT TIME OF


THIS DELIVERY


22. . (Years)


12 PLACE OF


BIRTH


(City or Town )


(State or country)


18 PLACE OF BIRTH Boston. (City or Town)


Mass.


(State or country)


13 OCCUPATION


19 INFORMANT


Conrad Dampolo


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? None


(c) How many previous fetal deaths of ANY gestation age? None


21 LENGTH OF 5 PREGNANCY , mos . completed weeks


22 Weight Lb. 2 Oz. 3 OF FETUS (or Grams)


23 WHEN DID FETUS DIE? Before Labor


24 AUTOPSY


Yes


No


25 FETAL DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


Unknown


Due To (b) Due To (c)


OTHER SIGNIFICANT


CONDITIONS


None


26


Holy Cross


Place of Burial or Cremation


DATE OF BURIAL


27 NAME OF FUNERAL DIRECTOR


ADDRESS


Vincent Rapino


East Boston, Mass.


Received and filed


April 2, 1963 XX


( Registrar )


A TRUE COPY ATTEST :


I HEREBY CERTIFY that this delivery occurred on the date stated above at 9 : 25 my andi product of conception was not a live birth.


Signature of Attending Physician or Medical Examiner :


M. D.


Anthony S. Ripa (PRINT OR TYPE NAME) 2 St. Andrew Road Date 19.


Address East Boston, Macs.


I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued :


Raph Ferrari (i) . (Signature of Agent of Board of llealth or other )


Health Offener (Official Designation )


april 2. 1463


(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).


10M-6-62-933404


1 Winthrop (City or Town)


Winthrop Community Hospital


St.


Baby Boy Velardo


2 NAME OF FETUS (if given)


None


None


X During Labor or Delivery Unknown


X


Malden (City or Town) April 3,19 63


.


FETAL DEATH


EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48, ACTS OF 1960.


Section 2A. "Examination of records and returns of 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.


FORM R-301


d for burial permit Board of Health its Agent. STRUCTIONS FOR AL CERTIFICATE


IT OR TYPE E OR CAUSES F DEATH not enter re than one use for each ), (b) and (c)


does not mean mode of dying. u heart failure. a, etc. It means sease, or compli- which caused


fitions, if any, h rave rise to e cause (€), og the under- : cause last.


nditions contrib- 'o death but mot to the terminal condition giver


53.8 47 714


IR 11 1963


$52-933404


PLACE OF DEATH


SUFFOLK (County) Boston (City or Town) BOSTON CITY HOSPITAL


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


Registered No.


02052


[(Il death occurred in a hospital or institution, St. { give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME ... Julia(Gannon) Cannon


(Il deceased is a married, widowed or divorced woman, give also maiden name.)


(W'as deceased a U. S. War Veteran, (if so specify WARD


No


104 Highland Ave. Winthrop, Mass. s. (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


3 DATE OF


DEATH


February 21.1963was a Patient (Month) (Day)


THEREBY CERTIEY December 22.1962 February 21.1963


I last saw h ...... alive on 19 ..... , death is said to


have occurred on the date stated above, at5 .. 22p.


m.


INTERVAL


BETWEEN


ONSET AND


DEATH


(a) Metastatic ... Carcinoma of Colon


Due To (b)


Due To (c)


OTHER


SIGNIFICANT Broncho Pneumonia


Day


8


16 BIRTHPLACE (City). (State or country ) New Found land


17 NAME OF FATHER John Mccarthy


18 BIRTHPLACE OF FATHER (City) (State or country)


Newfoundland


19 MAIDEN NAME


OF MOTHER


Elizabeth Rossiter


20 BIRTHPLACE OF MOTHER (City). (State or country)


Newfoundland


21 Informant


AGNES BINGHAMI


1187 Smith St. Providence R.I. tillress)


I HEREBY CERTIFY that a satisfactory standard certificate of death ledluh me BEFORE the bugal or transit permit was issued :


Fir. Fraca B05001


(Signature of Agent ol Board of Health or other) teb, 22 1963


( Registrar) (Official Designation) (Date of Issue ol Pergit)


A TRUE COPY ATTEST:


8 SEX


9 COLOR


10 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


(write the word)


Widowed


11 if married. widowed, or divorced HUSBAND of (Or) WIFE of Charles


(Give maiden Name of wie in lull)


CANNON


( Husband's name in lull)


12


AGI 88


Years .


Months


Days


lí under 24 hours


Ilours ..... Minutes


13 l'sual


Occupation :


Housework


( Kind of work done during most of iworking lile)


14 Industry


or Business:


OWN Home


15 Social Security No


CONDITIONS


Was autopsy performed ?


What test confirmed diagnosis?


linical


5 Was disease or injury in any way related to occupation of deceased? If so, specify ...


(Signature) M. D.


Frank c Gazpagnig Map.


(AND) UN CLIY HOSPITAL Date Feb, 22.9.63 Malden Holy CROSS 6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL,


Feb 23


1, 63


7 NAME OF FUNERAL I Frederick J. MAGRATH EAST Boston ADDRESS


Receivenand hled


FEB, 2 7 1963


63


(City or Town making this return)


-


(a) Residence. No ..


(C'ity or town and State)


###Female White


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Mos.


PARENTS


'A 'TRUE COPY ATTEST: Charles H. Mackie City Registrar


RECEIVED


OF TOW


OFFICE


10


{3}


CLERK


Co


6


HROR


APR 111963 AM


OUT - OF - TOWN


SUFFOLK


......


(County)


-


BOSTON


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


Registered No.


02302


[(If death occurred in a hospital or institution, .St. [ give its NAME instead of street and number) .......


PHYSICIAN - IMPORTANT


2 FULL NAME Alice R Jannini


(If deceased is a married, widowed or divorced woman, give also maiden name.)


113 Revere Street


(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


9 COLOR


10 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


(write the word)


Widowed!


11 If married, widowed, or divorced HUSBAND of


(Give maiden name of wife in full)


(or) WIFE


of Christie ANH


12


AGF: 56 Years


Months.


Days


If under 24 hours


... Hours ........ Minutes


13 L'sua]


Occupation :


CIT Nome


( Kind of work done during most working life)


14 Month's Industry or Business :


15 Social Security No.


16 BIRTHPLACE (City)


(State or country)


Thassa chusetts


17 NAME OF


FATIIER


James BoyLAN


18 BIRTHPLACE OF FATHER (City) (State or country) Geraina


19 MAIDEN NAME


OF MOTHER


ELISA Beth Sullivan


20 BIRTHPLACE OF MOTHER (City) ..... (State or country ) IreLand. .......


Bastara Carlson


113 Revere ST WiniTagutras


I HEREBY CERTIFY that a satisfactory standard certificate of death yas filed with me BEFORE the burial or transit permit was issued: 5. Warala Ra (Signature of Agent of Board of Health or other)


B15433 3-1-63 x2Charles qf Mackie ....... (Registrar )|| (Official Designation) (Date of Issue of Permit)


TX


A TRUE COPY ATTEST!


FORM R-301


ed for burial permit Board of Health r its Agent. STRUCTIONS FOR AL CERTIFICATE


NT OR TYPE E OR CAUSES F DEATH o not enter ore than one use for each ), (b) and (c)


does not mean mode of dying. as heart failure. ia, etc. It means sease, or compli- t which caused


ditions, if omy, ch gave rise to ce cause (a), ing the under- & conse last.


Conditions contrib. to death but mat d to the terminal e condition given . M. C.


20


620 138.


PR 11 1968 I Directon 1904 ICK Ink. 14


-62-932382


DECLINED, BY MEDICAL EXAMINER


PLACE OF DEATH


....


(City or Town making this return)


(Was deceased a


U. S. War Veteran,


(if so specify WAR)


Winthrop, Mass.


... St


(If nonresident, give city or town and State)


3 DATE OF


DEATH


February


2.7


1963


(Month)


(Day)


(Year)


THEREBY CERTIFY February 12 1 63 to February 27


That He attended deceased from


e I last saw h .... alive on


February 27


19.63.


death is said to


have occurred on the date stated above, at


3:30a .. m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


INTERVAL BETWEEN ONSET AND DEATH 9 Days


(a) Bronchopneumonia


Due To


(b)


Status Post Operation


Moore Prosthesis


Due To


(c) ......... Fractured ... Hip


OTIIER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


No


What test confirmed diagnosis ?


Clinical


5 Was disease or injury in any way related to occupation of deceased ?


If so, specify


(Signature)


....... ........


Charles L. Clay, M.D.


(Print or Type Name) (Address Asa's .. Dit., Mens. Gen.la.Hanp ......... Date ..


Feb. 271 63


6 Hoxy Gross L'.ate of Ilyrial or Cremation (City of Town)


DATE OF BURIAMarch


2


19.63


21 Informant


( Address)


7 NAME OF FUNERAL DIRECTOR Sanning, Sements


ADDRESS


224 WorthSE Boston


Received any filed




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