USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 2
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(City or Town)
January 13,
63
19
7 NAME OF
FUNERAL DIRECTOR
Torf Funeral Home
Chelsea, Mass.
ADDRESS
Received and filed
FEB 6 1963
19
( Registrar of City or Town where deceased resided )
A TRUE COPY
ATTEST :
( Registrar of City or Town where death occurred )
DATE FILED
January17,
.6.3
JX
10a If married. widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Julius Hollis
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGESLL
v
Months.
24 Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Not Determined
15 Social Security No.
BIRTHPLACE (City
(State or country)
Russia
17 NAME OF
FATHER
Morris Mason
18 BIRTHPLACE OF
FATHER (City)
(State or countryRussia
19 MAIDEN NAME
OF MOTHER
Bertha Shirley
( Signed )
Chiara N: MUSTAFA, M.D.
( Address )
Ha thorne, Mess.
1/15/
M. D.
63
Date.
19
20 BIRTHPLACE OF
MOTHER (City Russia
(State or country}
Mary F. Spechen
21
Informant
( Address )
Hathorne, More.
.
1
(County )
Danvers
(City or Town)
CERTIFICATE OF DEATH
Registered No.
§ (If death occurred in a hospital or institution,
2 FULL NAME
( Was deceased a
U. S. War Veteran.
(if so specify WAR,
8 SEX
19 63
63
2:50p,
INTERVAL
BETWEEN
ONSET AND
DEATH
Sales Clerk
DATE OF BURIAL
TH
FEB -61963 AM
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
ORM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town 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
X
PLACE OF DEATH
Fsaax (County )
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Donvers
(City or Town making this return)
6
No Denvery State Hospital, Hathorne St.
2 FULL NAME
Gertrude Fay
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No .... 120 Circuit Road
........
Length of stay: In place of death.
11 years 2 months 9
days. In place of residence .......... years .......... months .......... days.
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Jonuarv
12.
1963
(Month)
(Day)
(Year)
8 SEX
female
9 COLOR
white
10 SINGLE
( write the word)
MARRIED
WIDOWED
or DIVORCED married
4 I HEREBY CERTIFY,
That I attended deceased from
April 30, 1967
to ...
January 12
1963
I last saw
f.K.alive on !
Jon. 12.
53
., death is said to
have occurred on the date stated above, a de : 00p .. m.
INTERVAL
BETWEEN
ONSET AND
DEATH
Due Arteriosclerotic heart disease (b)
Due General Arteriosclerosis (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
no
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
tilard M
ausman
(Signed )
Willard M
alsman
M. D.
( Address )
Hathorne, Mass.
Date.
1/15/
63
19
Winthrop Cemetery, 6 Place of Burial or Cremation
winthrop
(State or country)
Unknown
21
Mary L
Sheehan
Informant
( Address )
Hethome, Mars.
7 NAME OF
FUNERAL DIRECTOR
C'Maley Einerel Home
ADDRESS Winthrop Mas
Received and filed
FEB 6 1963
19
( Registrar of City or Town where deceased resided )
A TRUE COPY
ATTEST :
( Registrar of City or Town where death occurred )
DATE FILED
January 17,
.19 ..
63
V.I.V
1
Danvers
(City or Town)
Registered No.
S (If death occurred in a hospital or institution,
( Was deceased a
U. S. War Veteran.
(if so specify WAR,
& Winthrop
Mass.
( Usual place of abode )
(If nonresident, give city or town and State)
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
James .... Fay
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGES3
.. Years3
6
Days
Months.
If under 24 hours
.Hours .....
.. Minutes
13 Usual
Occupation:
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
Not Determined
Dorchester
16 BIRTHPLACE (City)
(State or country)
ress.
17 NAME OF
FATHER
Meeney
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country )
Mass.
19 MAIDEN NAME
OF MOTHER
Elizabeth (Unknown)
20 BIRTHPLACE OF
MOTHER (City)
Unknown
DATE OF BURIAL
(City or Town)
January 15,
163
PARENTS
50M-9-59-926111
C
MEDICAL CERTIFICATE OF DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Pneumonia
(a)
ET!
6
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
F.E.B .... G1963.AM
X
PLACE OF DEATH
Suffolk (County)
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
(If deceased is a married, widowed or divorced woman, give also maiden name.)
-
(Was deceased a U. S. War Veteran, if so specify WAR). W.W. I
(a) Residence. No ...
155River Rd.
(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 .......... 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
11 If married, widowed, or divorcediriam Hambro HUSBAND of
(or) WIFE of.
(Husband's name in full)
12
AGE.68 .. Years.
.. Months.
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Accountant
(retired)
(Kind of work done during most working life)
14 Industry or Business:
15 Social Security No 020-14-4355"
Framingham,
16 BIRTHPLACE (City) (State or country) Mass.
17 NAME OF
FATHER
Edward Slattery
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Massachusett:
19 MAIDEN NAME
OF MOTHER
Mary Sahey
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Boston,
Mass.
6 Hand in Hand,
West Roxbury
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL January 13, 19 63
7 NAME OF
FUNERAL DIRECTOR
Benjamin F.Solomon
ADDRESS
420 Harvard Street, Brookline.
Received and filed
JAN- 14-1968
19.
(Registrar)
A TRUE COPY ATTEST: ATTEST:
1963
(Month)
12-
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
Nov
1952
to ........
JAN 12
19 63
I last saw hungalive on
JAN
11, 1963
death is said to
have occurred on the date stated above, at 3:23 A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cerebral Hemorrhage
Due To/
(b) Cerebral Arteriosclerosis
lup.
Due To (c)
OTHER
Pulmonary Emphysema
SIGNIFICANT
15yrs. CONDITIONS Coronary Artery Ytt, Disease Ux.
Was autopsy performed?
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 LIBER MAN
...
(Address)
WINTHROP, MASS Date Juni. 12 1963
(Print or Type Name)
PARENTS
21 Informant
Miriam Slattery
(Address)
155 River Road, Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Delft S. Lerama
-(Signature of Agent of Board of Health or other) 4222.12, 1963
(Date of Issue of Permit)
1
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.
ditions contrib- death but not to the terminal condition given
62-932382
1
Winthrop
(City or Town)
No
Winthrop Community Hospital
Martin F Slattery
...... ......
St
Winthrop, Mass.
3 DATE OF
DEATH
TAN
INTERVAL BETWEEN ONSET AND DEATH 18 /rs.
(Give maiden name of wife in full)
(Official Designation)
(City or Town making this return)
ORM R-301
SPACE FOR ADDITIONAL INFORMATION
11- 26 - 1917
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
9-30-1921
RANK, RATING
JAN 1 41963 AM Vermars 1ST Class Fun!
ORGANIZATION AND OUTFIT
R.S. Navy
SERVICE NUMBER.
NONE
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 deathly 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-302
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town 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
PLACE OF DEATH
Essex (County)
1
Danvers
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD
SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
Registered No.
8
Danvers State Hospital, Hathorne St. ( give its NAME instead of street and number) No
2 FULL NAME
Frank P. Hallett
( If deceased is a married, widowed or divorced woman, give also maiden name.)
U. S. War Veteran.
if so specify WAR
58 Otis
St
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 ...
5 months 12 days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January
18.
1963
(Month)
(Day)
( Year)
4 I HEREBY CERTIFY,
That I attended deceased from
August 6,
62
19.
to ..
January 18,
19.6.3
I last saw h.whalive on
January 18,, 163,
h is said to
8:450
INTERVAL BETWEEN ONSET AND DEATH
(b) Due Torteriosclerotic heart disease
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ?no
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
Willard
Hausman
(Signed) illard
housman
M. D.
Hathorne , Mass.
Date
1/22/
1963
6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
January 23,
.1963
19
21
Informant
( Address)
Ho thorne fass:
7 NAME OF
Alfred B Marsh
FUNERAL DIRECTOR
ADDRESS Winthrop ...
Moga.
Received and filcd
FEB 6 1963
19
ATTEST :
(Registrar of City'or Town where death occurred )
DATE FILED
January 25,
63
19
( Registrar of City or Town where deceased resided )
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
married
10a If married, widowed, or divorced
Unknown
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE7.8
Years.
.3 ... Months.1.7Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
022-05-6726
Everett
16 BIRTHPLACE (City)
(State or country)
Mass.
17 NAME OF
FATHER
warren
Hallett
PARENTS
18 BIRTHPLACE OF Cape Cod
FATHER (City)
(State or country) Mass.
19 MAIDEN NAME
OF MOTHER
Nellie Burse
20 BIRTHPLACE OF
Salem,
MOTHER (City)
Mass.
(State or country)
Mary
Sheehan
Winthrop Cemetery Winthrop
50M-9-59-926111
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
C
A TRUE COPY .
Danvers
(City or Town making this return)
S (If death occurred in a hospital or institution,
( Was deceased a
(write the word)
have occurred on the date stated above, at
m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
General Arteriosclerosis
(a)
Fruit & Produce (Wholesale)
111
FEB - 61963 AM
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
ORM R-301
for burial permit ard of Health ts Agent. TRUCTIONS FOR L CERTIFICATE
TOR 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
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib. death but not to the terminal condition given
1
62-933404
1
PLACE OF DEATH
SUFFOLK (County) WINTHROP (City or Town)
+ OVIETEM
ERTAT
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
(City or Town making this return,
STANDARD
CERTIFICATE OF DEATH
Registered No. 9
f(If death occurred in a hospital or institution, St. { give its NAME instead of street and number) PHYSICIAN - IMPORTANT
DOROTHEA (TAUCHEN) SAFFORD 2 FULL NAME.
(If deceased is a married, widowed or divorced woman give also maiden name.)
(a) Residence. No ..
94 LOCUST ST
(Usual place of abode)
st.
WINTHROP
(City or town and State)
Length of stay: In place of death .......... years ....
months .. days. In place of residence 44 ye 4years
.. months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
MARRIED
WIDOWED
DIVORCED
(write the word)
2
DIVONED
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Acute left ventricular
(a)
dilatation
INTERVAL BETWEEN ONSET AND DEATH
minut
(b)myocardial heart disease
yrs.
DuRheumatic heart disease
yrs.
14 Industry
or Business :
BEVERAGE CO.
15 Social Security No. 010-03-0444
16 BIRTHPLACE (City)
(State or country )
MASS
17 NAME OF FATHER JAMES TAUCHEN
18 BIRTHPLACE OF
FATHER (City)
(State or country)
AUSTRIA
19 MAIDEN NAME
OF MOTHER
ANNA M LISKA.
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
MASS
SOUTH BOSTON
21 Informant
MAS ANNA M. TAUCHEN
(Address)
44 LOCUST 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) Mac , 21
(Official Designation) FIN CK
(Date of Issue of Permit)
K PM V
TRUE CO COPY ATTEST:
(Year)
4 IHEREBY CERTIFY , That I attended deceased from
58
to.
January 18
19
63
June
19.
I last saw heRlive on
Jan. 18,
19 ... 63death is said to
have occurred on the date stated above, at
1:08 pm.
12
44 Years
Months.
.Days
If under 24 hours
.Hours ........ Minutes
13 Usual
Occupation :
CLERK
(Kind of work done during most of tworking life)
OTHER SIGNIFICANT CONDITIONS
pneumonitis, hepato- megaly with jaundice
4-5 days
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? NO If so, specify
(Signature) Josiple Arelaxil M. D. Joseph Gregorie, M.D. (Print or Type Name)
(Address)
194 Washington
.Date.Jan.18.163
Winthrop, Mass WINTHROP
6
WINTHROP
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
JAN
21
1963
7 NAME OF
FUNERAL DIRECTOR
MAURICE W. KIRBY
ADDRESS
WINTHROP
Received and filed
JAN 2 1 1963
19
( Registrar)
FEMALE
WHITE
(Was deceased a U. S. War Veteran, if so specify WAR)
3 DATE OF
DEATH
January 18,1963
(Month)
(Day)
WINTHROP COM. HOSP No ...
SOUTH BOSTON
PARENTS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
165
THROP
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 ofpersons! to whom they have given bedside care during a last ilmess from disease ufi! 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.
---
RM R-302
Egger
ISNO
(County )
1
Denvers
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Danvers
10
Danvers State Hospital, Hathorno St.
Michael Eruzione
(If deceased is a married, widowed or divorced woman, give also maiden name.)
( Was deceased a
U. S. War Veteran.
if so specify WAR,
No
(a) Residence. No ..
271 Bowdoin
St.
Winthrop,
Mass
( Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years ..
months
1.1.days. In place of residence .......... years .....
.months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Jenuary
22,
1953
( Month)
(Day)
(Year)
9 COLOR
8 SEX
male
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Widowed
4 I HEREBY CERTIFY,
deceased
January 11
53
19. to ...
I last saw h ...... alive on
January
22,
, 19.
death is said to
53
have occurred on the date stated above, at 9:10p. .. m.
INTERVAL BETWEEN ONSET AND DEATH
years
Due To (b) ...
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Bronchopneumonia
days
Was autopsy performed? no clinical & Laborate
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so. specify
(Signed) Iflera de frusman ausman
M. D.
( Address) Hathorne, Mess. Date. 19
1/22/
63
Holy Cross Cemetery, Malden, 6
Tings.
Place of Burial or Cremation
(City or Town)
January 26,
63
19
7 NAME OF
FUNERAL DIRECTOR
Vincent Rapino
F. Pastor,
Mass.
ADDRESS
Received and filed
FEB 6 ...... 1963
19
( Registrar of City or Town where deceased resided)
PARENT
ry 18 BIRTHPLACE OF
FATHER (City)
(State or country )
Italy
19 MAIDEN NAME
OF MOTHER
Meric, maiden name unk
20 BIRTHPLACE OF
Unknown
MOTHER (City)
( State or country)
Italy
21
Informant
.... J.p.thorne ......... p.s.s.
( Address )
A TRUE COPY
ATTEST :
( Registrar of City or Town where death occurred)
-
DATE FILED
January ..... 25,
19 63
50M-9-59-926111
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town 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
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON- THIS IS A PERMANENT RECORD
. C.
X PLACE OF DEATH
No ..
(City or Town making this return)
Registered No.
§ (If death occurred in a hospital or institution,
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE ....... 7.Years.
7
Months.
8
Days
If under 24 hours
.. Hours ........ Minutes
13 Usual
Occupation:
Leundry Worker
(Kind of work done during most of working life)
14 Industry or Business :
15 Social Security No.
029-10-7001
raples
16 BIRTHPLACE (City)
(State or country)
Italy
17 NAME OF
FATHER
Vincent Eruzione
Unknown
Stcehen
DATE OF BURIAL
That I attended
January 22
from
63
19
10a If married, widowed, or
Concetta Crissi
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
DEATH WAS CAUSED BY : IMMEDIATE CAUSE Arteriosclerotic heart disease (a)
2 FULL NAME
i!
SPACE FOR ADDITIONAL INFORMATION .... F.E.B. -. 61963. AM DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
X
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 filed for burial permit with Board of Health or its Agent.
11
(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.
(Usual place of abode)
5
Length of stay: In place of death
years.
. months
days. In place of residence .......... years.
.. months.
. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
JANI
.
DEATH
(Month) (Day)
23
1963
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
Novi
1958,
Jan 23.
,
19.63
I last saw h &Yalive on
Jan. 21,, 1963, death is said to
have occurred on the date stated above, at
5:30 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Arterioselevatic Heart
Disease,
INTERVAL BETWEEN ONSET AND DEATH 5yrs
Due
Hypertensive Heart
5 yrs
Due To (c)
OTHER
Cerebro Arteriosclerosis
5 yrs
CONDITIONS
and Epilepsy
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 ... . Charles Liberman (Signed) M. D. (Address) Winthropmass
Date. 1/23/ 1963
6
winthrop
linthrop.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
19
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS winthrop, lass.
Received and filed
JAN 25 1963
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widow
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Edgar B Brown
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
79
AGE
Years
6
Months.
10
Days
If under 24 hours
... Hours .....
Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
At home
15 Social Security No.
003-14-3316
16 BIRTHPLACE (City.)
(State or country)
Laine
17 NAME OF
FATHER
Charles F Noyes
18 BIRTHPLACE OF
FATHER (City)
Jefferson
(State or country )
Maine
19 MAIDEN NAME
OF MOTHER
Josephine Howe Clary
20 BIRTHPLACE OF
MOTHER (City)
Unable to obtain
(State or country ) -
21 Ralph Roach
Informant
(Address)
6 Grant Rd. Lynfield, Dass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issucd : taiph, E siberian. .. (Signature of Agent of Board of Health or other) 1.03)
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