USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 19
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4/6
63
Date
19
Woodlawn Crem.
6
Everett, Mass.
DATE OF BURIAL
April
9.
19
7 NAME OF
FUNERAL DIRECTOR
Alfred B. Marsh
174 Winthrop St. Winthrop
ADDRESS
Received and filed
MAY 10 1963
19
( Registrar of City or Town where deceased resided )
PARENTS
MOTHER (City)
( State or country)
Mrs. James Stavros
InformantB ..... N ..... Road Gloucester, Mass
( Address )
A TRUE COPY
ATTEST :
( Registrar of City or Town where death occurred)
DATE FILED
April
19 03
X
ORM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
Due To (b) 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 Due To (c)
50M1-9-59-926111
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
NO
What test confirmed diagnosis ?
Physcial Exam
No
5 Was disease or injury in any way related to occupation of deceased ?
If so. specify
( Signed )
W.M.Poland
M. D.
Place of Burial or Cremation
(City or Town) 63
21
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
( write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
8:30P
have occurred on the date stated above, at .. m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Arteriosclerosis general
(a)
INTERVAL BETWEEN ONSET AND DEATH over
19
(Kennedy)
( Was deceased a
U. S. War Veteran.
(if so specify WAR
NO
( If nonresident, give city or town and State)
April
Ella Margaret Graff
Registered No. .
N.Y.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
R-305 1
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) . the time of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided
PLACE OF DEATH
Egsex (County)
Danvers
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Denvers
(City or town making return)
Registered No. .......
§ (If death occurred in a hospital or institution, No. Danvers State Hospital, Hathorne
.. St. [ give its NAME instead of street and number)
2 FULL NAME Margaret MacCarthy (Shea)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
66 Summitt Avenue
Winthrop, Mass.
(a) Residence. No.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years.
1
months.
s .. ].9 .... days. In place of residence ............. years ..........
.... months .............. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
April
15,
1963
(Month) (Day)
(Year)
female
white
12a If married, widowed, or divorced
HUSBAND of
(Giye maiden name of wife in full)
(or) WIFE of
John T. Mccarthy
(Husband's name in full)
13 DATE OF BIRTH
14
AGE87
Years .
0
Months.
6
Days
If under 24 hours
.. Hours
Minutes
15 Usual
Occupation:
Unable to work
(Kind of work done during most of working life)
16 Industry or Business :
17 Social Security No.
024-09-9797
18 BIRTHPLACE (City)
....
(State or country)
So. Wales, England
19 NAME OF
FATHER
Patrick Shea
20 BIRTHPLACE OF
FATHER (City)
(State or country)
Unknown
England
21 MAIDEN NAME
OF MOTHER
Margaret Dacey
Unknown
22 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
23
Informant
(Address)
Hathorne, Mass
A TRUE COPY
ATTEST:
........
I (Registrar of Chy or Town where death occurred)
DATE FILED
April 17,
63
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR
11 CITIZEN
OF U.S.
YES
NO
12 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
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.) Arteriosclerosis, fracture left
hip , before adm. to hospital
5 Accident, suicide, or homicide (specify)
accident
Date and hour of injury
F.b. 15,
19.
63
If accidental, was injury causally related to the death?
no
Where did
Winthrop
Injury occur ?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in
public place ?
Com. Hospital
(Specify type of place)
Manner of
F 11 to floor
Injury
(How did injury occur?)
Nature of
Fract. left hip
Injury
While at work?
no
Was autopsy performed? n.O.
6 Was disease or injury in any way related to occupation of deceased ?... n.c If so, specifR .l.ph ..... ..... Foss
(Signed)
Ralph E Foss
M. D.
(Address)
Peabody,
Mass
Date ....
4/15 1963
Winthrop Cemetery, Winthrop 7 Place of Burial or Cremation. (City or Town)
DATE OF BURIAL
April 18,
1963
8 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS
Winthrop,
Mass
Received and filed
MAY-10-1963
19.
T
:
.
1
PARENTS
Unknown
Mary E Sheehan
25M - 3-61-930213
(City or Town)
f(Was deceased a
U. S. War Veteran,
if so specify WAR)
No
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING .... ORGANIZATION AND OUTFIT SERVICE NUMBER
RM R-304
PLACE OF DELIVERY No.
SUFFOLK (County )
Winthrop
(City or Town)
Winthrop Community Hospital
1
(If death occurred in a hospital or institution, give its NAME instead of street and number)
3 DATE OF
DELIVERY
May
2
1963
(Month )
(Day)
(Year)
4 SEX
Male ...... Female X Undetermined ..
5 COLOR (if
determined)
W.
6 THIS BIRTH (Check one)
Single L . Twin ....
Triplet
7 IF MULTIPLE BIRTH, BORN :
1st ..
.. 2nd
3rd
FATHER
8
FULL
NAME
Raymond, Otter
14
MAIDEN NAME
Cynthia. Herbert
PRESENT NAME
Cynthia Otter
9
RESIDENCE, NO.
142 Fauline St.
STREET
CITY OR TOWN
T
inthron
STATE
... Mas.s.
15
RESIDENCE, NO.
CITY OR TOWN
inthrop
STATE.
Mass
10 COLOR OR ,
RACE
hit.e .. ..
11 AGE AT TIME OF
THIS DELIVERY
27 (Years)
16 COLOR OR
RACE .. .
Y hitel
17 AGE AT TIME OF
THIS DELIVERY
21
(Years)
12 PLACE OF
BIRTH
McGregor
mexas.
(State or country)
(City or Town)
18 PLACE OF BIRTH in-hrop, (City or Town)
Mass
(State or country)
13
OCCUPATION
Mechanic
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
1
(a) How many children are
now living?
1
(b) How many children were
born alive
dead?
but are now None
(c) How many previous fetal deaths of ANY gestation age? None
21 LENGTH OF
PREGNANCY
completed weeks
28
22 Weight Lb. 2 Oz. 13
OF FETUS
(or
23 WHEN DID FETUS DIE? X Before Labor
During Labor
or Delivery
Unknown
24 AUTOPSY Yes No
X
25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Premature rupture of membranes
Due To (b) Due To (c)
OTHER SIGNIFICANT CONDITIONS
26
Winthrop Com
Winthrop
(City or Town)
Place of Burial or Cremation
16-3
DATE OF BURIAL
3,
27 NAME OF
FUNERAL DIRECTOR Ichard C. Kirby Inc.
ADDRESS
917 Bennington St JE. Boston
Received and filed
MAY 3 - 1963
19
( Registrar)
MOTHER
..
In giving AUSE OF AL DEATH not enter re than one use for each f (a), (b) and (c)
/ or maternal, ition causing 1 death (do use such s as stillbirth rematurity.) l and/or ma- al conditions, y, which gave : to above e (a), stating underlying e last.
litions of fetus hother which have contrib- dd to fetal b, but, in so as is known. not related ause given a ).
(PRINT OR TYPE NAME)
Address
73 Bartlett Rd.,
Winthrop, Mass.
Date May 2 1963
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued:
G Levianni (B)
( Signature of Agent of Board of Health or other )
Health officer
(Official Destination)
May 3. 1963 (Date of Issue of Permit )
· X
A TRUE COPY ATTEST :
To be filed for burial permit with Board of Health or its Agent.
Registered No.
93
1
2 NAME OF FETUS
(if given)
Faby Girl Otter
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)
St.
142 Pauline St.
„STREET
19 INFORMANT Raymond
Otter
Grams)
I HEREBY CERTIFY that this delivery occurred on the date stated above at10;16pm., and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner : M. Traunstein 1
M.D.
10M-6-62-933404
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.
ORM R-301
for burial permit oard of Health its Agent. TRUCTIONS FOR L CERTIFICATE
OR TYPE OR CAUSES 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
tions, if any, gave rise to cause (a), & the under- cause last.
sditions contrib- death but not to the terminal condition given
PLACE OF DEATH
Suffolk (County)
WUL
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
§(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME Ellen .... M ........ Skehan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
35 Enfield Road
(Usual place of abode)
St
(If nonresident, give city or town and State)
Length of stay : In place of death.3 .. 5.years.
months ......... days. In place of residence 35 ears.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWEDN
DIVORCE Widowed
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
Thomas E. Skehan
(Give maiden name of wife in full)
(or) WIFE
of
(Husband's name in full)
12
87
AGE
Years.
.Months ...
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most working life)
14 Industry
or Business:
Own Home
15 Social Security No ....
16 BIRTHPLACE (City)
(State or country )
East .... Boston
Mass
17 NAME OF
FATHER
Dennis Harrington
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Mary Mccarthy
20 BIRTHPLACE OF MOTHER (City ) .. (State or country) Ireland
Robert W. Skehan
21 Informant
(Address)
35 Enfield Rd., 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) Health officer May 3, 1963
(Date of Issue of Permit)
T
A TRUE COPY ATTEST:
:
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
May 2 1963
(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
6:30 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Death presumably due to
INTERVAL
BETWEEN
ONSET AND
DEATH
Due Tonatural causes, probably (b)
a cerebro vascular
(c)
occlusion on basis of history
OTHEROF
arteriosclerosis and hypertension
CONDITIONS
SIGNIFICANT
Winthrop Board of Health
Was autopsy performed?
Charles Liberan Mim
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? ho If so, specify
(Signature)
Charles
Lettera
M. D.
CHARLES
LIBERMAN
(Address)
(Print or Type Name)
WINTHROP MASS Date
5/3/
19 63
Holy Cross
Malden
6 Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
May 6,
19. 63
7 NAME OF
FUNERAL DIRECTOR
Arthur J O'Maley
ADDRESS
Winthrop Mass MAY 3- 1963
Received and filed 19
....
(Registrar)|| (Official Designation)(
62-932382
-
Winthrop
(City or Town)
No ...
35Enfield Road
(City or Town making this return)
(Was deceased a
U. S. War Veteran,
(if so specify WAR).
... months .......... days.
(write the word)
PARENTS
.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
MAY 3 1963 PM
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.
X
Suffolk
150slow 6-6-63
LIBERTATE
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No. .......
.......
S(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
(a) Residence. No ..
136 Trenton Street,
(Usual place of abode)
st.East .... Boston , Ma.s.s ..
(If nonresident, give Lity 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
DEATH
May
3
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
May 20
191962
to ...
14 ay
3
That I attended deceased from
19 63
I last saw h. malive on
inclu 2
19% ... ), death is said to
have occurred on the date stated above, at GCT, Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Lolar Pneumonia.
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Cerebral Hemmelige
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)
M. D. Charles T. Ferrerd
(Address)
(Print or Type Name) 154 (JEjun, 182 11 Date.
5/3
19 4.3
6
Woodlawn Cemetery
Everett.
(City or Town)
DATE OF BURIAL
19 ..... 6.3
7 NAME OF
FUNERAL DIRECTOR
Vincent Rapino
ADDRESS
9 Chelsea St. East Boston Mass
Received and filed
MAY 6 -1963
19
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
widowed
11 If married, widowed, or divorced HUSBAND of
Maria Panarinto
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE
Years
.....
.Months.
Days
79
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Retired
14 Industry
or Business :
****
15 Social Security No .. 0:31-10-4755
16 BIRTHPLACE (City)
(State or country)
Italy
17 NAME OF
FATHER
Rosario Recca
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
Rosa Lentini
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
21 Informant
Angelo Recca (son)
(Address)
136 Trenton St., East Boston, Mass.
:
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Ralph to Serianni (Signature, of Agent of Board of Health or other) Health officer Darauf 6- 1963
(Date of Issue of permit)
X
.
does not meon de of dying, heart foilure, etc. It meons ase, or compli- which coused
ions, if ony, gove rise to couse (0), the under- couse lost.
ditions contrib- death but not to the terminal condition given
PLACE OF DEATH
(County) Winthrop
(City or Town)
May flower Nursing Home No
2 FULL NAME
Juneppe
Recca
(If deceased is a married, widowed or divorced woman, give also maiden name.)
3
2 2-932382
(Registrar) | (Official Designation)
A TRUE COPY ATTEST:
.
:
PARENTS
Place of Burial or Cremation
May 6.
. OVIETEN
(City or Town making this return)
1
ORM R-301
for burial permit oard of Health its Agent. TRUCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH not enter e than one e for each (b) and (c)
PERSONAL AND STATISTICAL PARTICULARS
INTERVAL BETWEEN ONSET AND DEATH 5 days
(Kind of work done during most working life)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY: SERVICE
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
MAY-61963 AM
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 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.
.
1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
No ..
40 Shirley Street
S(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)
N.O.
(a) Residence. No.
40 Shirley Street
St
(Usual place of abode)
Length of stay: In place of deat. 30.year _. ....... months. LIdays. In place of residence61.years ....... Conths .. ]]days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
May
11
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
6-17
61
5-11-
to ...
.6.3.
I last saw hhlive on
May 10
16.3., death is said to
have occurred on the date stated above, at .6 :. 2.5a ... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) .... acute ..... myocardial ..... infartim ..
Due Toarteriosclerotic heart (b) disease.
3yrs
Due To
generalized
(c) arteriosclerosis
5yrs
8 SEX
9 COLOR
White
10 SINGLE
„(write the word)
MARRIEDMarried
WIDOWED
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of Myrtle .... May ..... Ackerman.
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE ... 67Years ..... 5 Months .. ]] Days
If under 24 hours
Hours ..
Minutes
13 Usual
Occupation :
Foreman
(Kind of work done during most working life)
14 Industry
or BusiwinthropWater Department
15 Social Security No ......
010-09-8907
Winthrop
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF FATHER Robert Cobb
PARENTS
18 BIRTHPLACE OF
FATHER (City)
Prince Edward Island
(State or country)
Canada
19 MAIDEN NAME
OF MOTHER
Alma Coliette Floyd
20 BIRTHPLACE OF
MOTHER (City)
Winthrop
(State or country)
Massachusetts
21 Informant
Mrs ....... Louis R. Cobb
(Address)
40 Shirley St. Winthrop
Mas HEREBY CERTIFY that a satisfactory standard certificate of death Was Thiled with me BEFORE the burial or transit permit was issued: Eceph 6. Alivianon (3)
Signature of Agent of Board of Health or other) Health office
Day 13-6 3
(Official Designation) (
(Date of Issue of Permit)
T
A TRUE COPY ATTEST:
52-932382
FORM R-301
I for burial permit oard of Health its Agent. TRUCTIONS FOR L CERTIFICATE
T OR TYPE OR CAUSES DEATH not enter e than one se for each , (b) and (c)
does not mean ode of dying, : heart failure, , etc. It means ase, or compli- which caused
tions, if any, gave rise to cause (a), g the under- cause last.
ditions contrib- death but not to the terminal condition given
Was autopsy performed?
no
What test confirmed diagnosis ?clinical & lab
5 Was disease or injury in any way related to occupation of deceased ?n.O If so, specify
(Signature)
Mr. Traunstein
M. D.
M. Traunstein, Jr., M.D.
(Print or Type Name)
(Address)
73 Bartlett Rd ....... Date ...
5-11
196.3
Winthrop, Mass .
6.
Winthrop Cemetery Winthrop Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
May 14,1963
7 NAME OF
FUNERAL DIRECTOR
alfred B. March
ADDRESS
174 Winthrop St. Winthrop,
Received and filed
MAY 13 1963
19
(Registrar) |
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD . OVIETEM CERTIFICATE OF DEATH LIDERTATE
(City or Town making this return) ....
Registered No.
2 FULL NAME
Louis Russell Cobb
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PERSONAL AND STATISTICAL PARTICULARS
Male
INTERVAL
BETWEEN
ONSET AND
DEATH
12 hr
OTHER
SIGNIFICANT
CONDITIONS
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 : MAY 1. 21052 PM
(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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