USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 20
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(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.
RM R-301
OR TYPE R CAUSES EATH t enter han one for each b) and (c)
s not mean of dying, eart failure, tc. It means or compli- hich caused
s, if any, ve rise to ause (a), the under- ause last.
ions contrib- eath but not the terminal dition given I.C.
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
Registered No.
(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME.
Florence May Gingrich( Benson )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
49 Waldemar Avenue
Winthrop, Massachusetts
(If nonresident, give city or town and State)
Length of stay: In place of death ........ years.
......... months .......... days. In place of residence ..
.5€ rs .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
May
15
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
2:30 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Death due to natural causes
INTERVAL
BETWEEN
ONSET AND
DEATH
Due To
(b)
presumably coronary occlusion
(c)
Due Toon
basis of history.
Winthrop Board of Health
OTHER
SIGNIFICANT
CONDITIONS
Charles Libermais, Mal
Was autopsy performed ?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
(Signature)
Charles
Liberar, M. D.
CHARLES
LIBERMAN.
(Print or Type Name)
(Address)
Wirttrap, he45Date.
5/16/1963
Woodlawn Cemetery, Everett, Mass
6
I'lace of Burial or Cremation
(City or Town)
DATE OF BURIAL
May 18, 1963
19.
7 NAME OF
FUNERAL DIRECTOR
alfred B.Marsle
ADDRESS
174 winthrop St. Winthrop
Received and filed
MAY 17 1963
19
( Registrar)
8 SEX
9 COLOR
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
widowed
female
white
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
John Edward Gingrich
(Husband's name in full)
12
AGE .. 7.O.Years.
Months ..
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Office mamager
(Kind of work done during most working life)
14 Industry
or Business :
Boston Y W .C .4.
15 Social Security No ..
025-26-0168
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
Edgar Nicol Benson
PARENTS
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Mary Flora Gorman
20 BIRTHPLACE OF
MOTHER (City).
Boston
(State or country)
Massachusetts
21 Informant
(Address)
Harry N. Benson
290 Elm St. Walpole, Mass.
. HEREBY CERTIFY that a satisfactory standard certificate of death Mast with me BEFORE the burial or transit permit was issued : -
.......
(Signature of Agent of Board of Health or other)
Wealth officer
May 17,1963
(Official Designation) (Date of Issue of Permit)
T VIVI
A TRUE COPY ATTEST:
6 932382
1
or burial permit d of Health Agent. ICTIONS
OR CERTIFICATE
No.
49 Waldemar Avenue
(City or Town making this return)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
(Usual place of abode)
PERSONAL AND STATISTICAL PARTICULARS
Boston
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE:
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
500
THROP
RULES OF PRACTICE U HAT 1 71503 Th
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.
RM R-301
or burial permit rd of Health s Agent. UCTIONS FOR CERTIFICATE
OR TYPE R CAUSES DEATH
ot enter than one for each (b) and (c)
es not mean of dying, heart failure, etc. It means e, or compli- which caused
s, if any, ave rise to cause (a), the under- cause last.
itions contrib- death but not the terminal ndition given
PLACE OF DEATH
SUFFOLK
(County)
NSE
1
WINTHROP
(City or Town)
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. Į give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME. JOHN FRANCIS GALLAGHER
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No ....
109
Pleasant Street
St
Winthrop
(Usual place of abode)
Length of stay: In place of death629 years months.
.. days. In place of residence ..... Myears .......... months .......... days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
SINGLE
11 If married, widowed, or divorced HUSBAND of
(or) WIFE of.
(Husband's name in full)
12
74
AGE.
Years
Months ..
.. Days
If under 24 hours
Hours .....
Minutes
13 Usual
Occupation :
Photo-Engraver
(ret.)
(Kind of work done during most working life)
14 Industry
or Business :
Donovan & Sullivan Co.
15 Social Security No ....
16 BIRTHPLACE (City)
(State or country )
Irerand
17 NAME OF
FATHER
Daniel Gallagher
18 BIRTHPLACE OF
FATHER (City)
Donegal
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Mary Bradley
Derry
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21 Informant
Miss E. Veronica Gallagher
(Address)
100 Pleasant St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph
(Signature of Agent of Board of Health or other)
Legitti offer
Thay ir0. 19 63
(Date of Issue of Permit)
2-932382
A TRUE COPY ATTEST:
INTERVAL BETWEEN ONSET AND DEATH
Due Tonatural causes, probably
(b)
acute coronary occlusion
Due To
(c)
on basis of history
Wirtherap Board of Health
OTHER SIGNIFICANT CONDITIONS Charles Liberman In
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
Clicples
... M. D.
CHARLES LIBERMAN
(Print or Type Name)
(Address) WINTHROP, MASS Date
5/17/1963
6
Holy Cross
Malden
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
May
21,
19.63
7 NAME OF
FUNERAL DIRECTOR
FRANK H. CARP
ADDRESS
79 Elm
St. Charlestown
Received and filed
MAY 20 1963
19
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
MAY
17
1963
(Year)
(Month)
(Day)
4 IHEREBY CERTIFY , That I attended deceased from
19
to ..
19
I last saw h ...... alive on
19 ........ , death is said to
(Give maiden name of wife in full)
have occurred on the date stated above, at
9:05Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE (a) Death presumably due to
No
109 Pleasant St. ,Winthrop
(City or Town making this return)
(Was deceased a U. S. War Veteran, (if so specify WAR)
No
(If nonresident, give city or town and State)
(Registrar) || (Official Designation)
Don
PARENTS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
YTHEOR
MAY 201963 AM
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice: (1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor - tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
RM R-301
1
Winthrop
(City or Town)
No.
283
Court Road
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
No
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
283 Court
Road
Winthrop
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death.
19
.. years .......... months .......... days. In place of residence ..... ].years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
11 If married, widowed, or divorced HUSBAND of .. Emma .. K .Kinsella
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
2-7-1911
12
AGE ... 52 Years.3.
Months.14 ..... Days
If under 24 hours
Hours ..
Minutes
13 Usual
Occupation :
Retired-Civil Engineer
(Kind of work done during most working life)
14 Industry or Business :
15 Social Security No ...
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
William W.K.Campbell
Boston
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Elizabeth J.Crowley
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass.
21 Informant Mrs .EMMA ... K.Campbell ( Address) 283 Court Rd., WINTHROP Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph 6.
(Signature of Agent of Board of Health or other) (Nes) ....
Health Officer )ha, 13.1963
(Date of Issue of Permit)
A TRUE COPY ATTEST:
PARENT!
6
WINTHROP CEMETERY
WINTHROP
I'lace of Burial or Cremation
(City or Town)
DATE OF BURIAL
MAY
24
1963
7 NAME OF
FUNERAL DIRECTOR
ARTHUR PORCELLA
ADDRESS
BEACHMENT, MASS.
Received and filed
MAY 23 1963
19
8 SEX
3 DATE OF
DEATH
MAY 21 1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
MAY 1,
1963
to ...
MAY 21,
196.3
I last saw hfMalive on
MAY 20,
19.63, death is said to
have occurred on the date stated above, at 3:10 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) CORONARY THROMBOSIS
INTERVAL BETWEEN ONSET AND DEATH
Due To.
ARTERIOSCLEROSIS
2 YRS
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
PREVIOUS ATTACK
4YRS
Was autopsy performed?
NO
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
YES
(Signature)
a. n. Carlan
M. D.
1. N. CAPLAN UD
(Print or Type Name)
(Addre 186PRINCETONST EAST BOSTON MAY 2 1963
PLACE OF DEATH
Suffolk
(County)
J. OVIETEM-
LIBERTATE
WINTHROP
(City or Town making this return)
or burial permit rd of Health Agent. ICTIONS
OR CERTIFICATE
OR TYPE R CAUSES EATH
t enter han one for each b) and (c)
es not mean of dying, eart failure, tc. It means , or compli- kich caused
as, if any, ve rise to ause (a), the under- ause last.
ions contrib- eath but not the terminal dition given M.C.
2-932382
Warren M. Campbell
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
St
(If nonresident, give city or town and State)
(Registrar ) || (Official Designation)
Revere
(b)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE. RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .-- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor - tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
RM R-301
r burial permit 'd of Health Agent. CTIONS OR ERTIFICATE
R TYPE CAUSES CATH t enter han one or each ) and (c)
s not mean of dying, eart failure, c. It means or compli- ich caused
s, if any, ve rise to ause (a), he under- use last.
ions contrib- cath but not the terminal dition given IR.
PLACE OF DEATH
Suffolk
(County)
Winthrop (City or Town)
No ..
39 Grovers Ave
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD SOVIETEM CERTIFICATE OF DEATH LIBERTATE
(City or Town making this return)
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
Daniel J. Geary
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(if so specify WAR)
(a)
Residence. No ..
66 Winthrop Shore Drive
(Usual place of abode)
St
(If nonresident, give city or town and State)
Length of stay: In place of death2 years.
.years .......... months.
......
.days. In place of residence.O.
years.
.months ..... ... days.
:
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
(write the word)
Malele
White
10 SINGLE
MARRIED
WIDOWED
DIVORCEIMarried
UNKNOWN
11 If married, widowed, or divorsed
HUSBAND of
Mary F.
Geary ( Reardon
(or) WIFE of ..
(Husband's name in full)
12
AG8.5
Years.
Months.
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Accountant
(Kind of work done during most working life)
14 Industry
or Business :
N.E.News Co
, 15 Social Security No ..
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
John Geary
-
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Boston
Mass
19 MAIDEN NAME
OF MOTHER
Mary Burns
20 BIRTHPLACE OF
MOTHER (City)
Boston,
Mass
(State or country)
Mary F. Geary
21 Informant
( Address)
66 Winthrop Shore Drive
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 Fever
77201 23,196 3
(Official Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased fron
60
to 2 css
21
1963
I last saw h.4.palive on
196, death is said to
have occurred on the date stated above, at 5.15 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
myocardial Hear Disease
Due To
(b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Sendity
Was autopsy performed?
72
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ?...
If so, specify
(Signature)
mente Lazone
M. D.
JGraph Gregario
(Print or Type Name) que /22 961
(Address)
194 Washington Date
6 .New Calvary
Boston ........ Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
May 24,
19.
63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O' Maley
ADDRESS
Winthrop Mass.
Received and filed
MAY 23 1963
19.
(Registrar)
62932382
I
Registered No.
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
no
3 DATE OF
DEATH
May21 1963
INTERVAL BETWEEN ONSET AND DEATH
(Give maiden name of wife in full)
PARENTS
.
·
Boston
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un - related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor - tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion bad 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)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
[(If death occurred in a hospital or institution, St. Į give its NAME instead of street and number)
2 FULL NAME.
Amelia.M ..... Thibeau
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ....
144 Main Street
(Usual place of abode)
Length of stay: In place of death. 2.5years ...
... months .. days. In place of resideno 25.) ..... months ... .. days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
11 If married, widowed, or divorced HUSBAND of
(or) WIFE
of
(Give maiden name of wife in full)
Clifford Thibeau
(Husband's name in full)
12
AGE
56.
10 Months: 28
.Days
If under 24 hours
Hours ... ... Minutes
13 Usual
Occupa
Senior .Clerk
(Kind of work done during most working life)
14 Industry
or Business:
Winthrop Water Dep't
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Lowell, Mass
17 NAME OF
FATHER
John Stempien Stymping
18 BIRTHPLACE OF
FATHER (City) ..... Cannet ... be learned
(State or country)
Austria
19 MAIDEN NAME
OF MOTHER
ANNIE
You' aka
Cannot be learned
20 BIRTHPLACE OF MOTHER (City) .... Cannot be learned (State or country)
Austria
21 Informant
(Address)
Robert Thibeau
144 Main St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: d'aple 16 Serianni (a)
(Signature of, Agent of Board of Health or other)
Heaith Gifeur
Muy 2 3, 1963
(Date of Issue of Permit)
A TRUE COPY ATTEST:
:
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
May21 1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
non
58
19
That I attended deceased from
to ...
May
14
1903
I last saw Ha ... alive on
May
14
63
19.
death is said to
have occurred on the date stated above, at
3:40Pm
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Myocardial infarction
INTERVAL BETWEEN ONSET AND DEATH
(a)
Due To
coronary arteries derosis
(b)
Due To (c)
OTHER
SIGNIFICANT
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