USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 23
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SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING. ....
ORGANIZATION AND OUTFIT.
SERVICE NUMBER
X
PLACE OF DEATH
Suffolk (County)
I
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.
f(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
453 Shirley St.,
St
(If nonresident, give city or town and State)
Length of stay: In place of death. 2= .years .......... months .......... days. In place of residence .. 74years ......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June ..... 13 .....
.. 1963
(Month)
(Day)
(Year)
4 IHEREBY 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
1:05Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE El presumably due to natur
INTERVAL BETWEEN ONSET AND DEATH
Due ToCauses, probably acute (b)
Coronary occlusion on
Due Tobasis lof history and (c)
OTHER
SIGNIFICANT
Heatment
Winthrop Bogaty Health
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
M. D.
CHARLES
LIBERMAN
(Print or Type Name) (Address) WINTHROP MASS Date
6/13/1962
6
Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
June ..... 1.5.
19 .. 63
7 NAME OF
FUNERAL DIRECTOR Arthur ...... J ........ Maley
ADDRESS
Winthrop, Mass.
Received and filed
JUN 14 1963
19
( Registrar)|
A TRUE COPY ATTEST:
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
WIDOWEIWidowed
DIVORCEIN
UNKNOWN
MARRIED
!! If married, widowed, or divorced
HUSBAND of
Margaret.M ....... Mooney
(or) WIFE of
(Husband's name in full)
12
74
AGE
Years
Months ...
.Days
If under 24 hours
Hours ......
Minutes
13 Usual
Occupation :
Retired Fireman
14 Industry
or Business :
Fire ..... Dep't
15 Social Security No.
16 BIRTHPLACE (City) (State or country ) Mass
17 NAME OF
FATHER
William N. Flanagan
18 BIRTHPLACE OF
FATHER (City)
East Boston
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Margaret McQuarrie
20 BIRTHPLACE OF MOTHER (City Cannot .... be .... learned (State or country)
( Address) Arthur ... J ...... O' Maley
79 Atlantic St., Winthrop Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : PorpleTE Sirvanme (6) (Signature of Agent of Board of Health or other)
Heritt Offen Seine 14 1963
(Official Designation)
(Date of Issue of Permit)
KUI.V
rial permit Health ent. ONS
FICATE
"YPE AUSES H ter one ach nd (c)
t mean dying, failure, ! means compli- caused
any, ise to (a), under- last. contrib- but not terminal n given
R-301
(City or Town making this return)
No. 4.53 Shirley ..... St.,.
John W. Flanagan
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
No
if so specify WAR)
(Usual place of abode)
PERSONAL AND STATISTICAL PARTICULARS
(Give maiden name of wife in full)
(Kind of work done during most working life)
Winthrop,
PARENTS
382
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 2 11
(3) Medical Examiners will investigate and certify to alldeaths 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 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.
R-301
1
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
(City or Town making this return)
Registered No.
f(If death occurred in a hospital or institution,
No
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.)
33 Hutchinson St.
......
St
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months.
.days. In place of residence .O .... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCEIMarried
UNKNOWN
(write the word)
(Month)
(Daý)
(Year)
4 I HEREBY CERTIF
May 29
19
63
June 16
19
That I attended deceased
From
63
I last saw h.1 @live on
June
16 1963
death is said to
have occurred on the date stated above, at
1 : 10P .M.
INTERVAL BETWEEN ONSET AND
(or) WIFE of
(Husband's name in full)
(a)
Due
(b)
"Coronary Arteriosclerotic Heart Disease
(c)
Due
Hypertension
2 yrs
· 14 Industry
or Business :
N.E.Tel & Tel Co
15 Social Security No.
16 BIRTHPLACE (City)
East .... Boston
(State or country) Mass
Was autopsy performed?
Yes
What test confirmed diagnosisClinical ,.Post ..... mortem
5 Was disease or injury in any way related to occupation of deceasedNO .. If so, specify ...
(Signature)
estes Liter
Charles Liberman, M.D.
(Print or Type Name)
(Address)
Winthrop., ...... Mass .... Dat.6./.1.6/
19 .. 63.
6
HolyCross Cemetery
Malden.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
June 19
19
63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS
Winthrop Mass.
Received and filed
JUN 18 1963
19
(Registrar)
A TRUE COPY ATTEST:
PARENTS'
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Boston
Mass
19 MAIDEN NAME
OF MOTHER
Johanna Hurley
20 BIRTHPLACE OF
MOTHER (City)
Toledo
(State or country)
Ohio
21 Informant
Ida Reagan
(Address)
33 Hutchinson 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 to Leriane (8)
(Signature of Agent of Board of Health or other)
Hinthoffen
fame 18-63
(Official Designation)
(Date of Issue of Permit)
82
al permit Health it. IS ICATE
PE USES 1
r ne ch 1 (c) mean dying, failure, means .om pli- caused
any, e to (a), der- last. contrib- ut not rminal given
OTHER
Adenocarcinoma of Urin
SIGNIFICAN
CONDITIONS ary Bladder
2 yrs
12
AGE.73
.Years
Months .......
.. Days
If under 24 hours
.Hours ......
.. Minutes
13 Usual
Occupation :.
Retired Telephone Worker
(Kind of work done during most working life)
1 yr
11 If married, widowed, or divorced
HUSBAND of
Ida .... Metz
(Give maiden name of wife in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Coronary Artery Occlusion
9
Winthrop Communtiy Hospital
Andrew J. Reagan
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
No
(a) Residence. No ...
(Usual place of abode)
3 DATE OF
DEATH
June 16, 1963
to ..
17 NAME OF
FATHER
James Reagan
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
'li
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 b . C 1963 AM 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 Deatb .- 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)
ENSF PFT
Winthrop (City or Town)
No. Winthrop Community Hospital
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
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)
WW1
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
18 Dolphin Ave
St.
Winthrop
(Usual place of abode)
Length of stay: In place of death .............. years ..
... months.
4 Hrs
days.
În place of residence.
.years ..
.......
.months.
......
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June
16
1963
(Month)
(Day)
(Year)
4 I
HEREBY CERTIFY,
That I attended deceased from
Nov
1961
to ...
June 16
1963
I last saw helalive on
1440 16
, 19 63, death is said to
have occurred on the date stated above, at
4:30 A.m.
INTERVAL
BETWEEN
ONSET AND
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE .. 6.9 .. Years.
.Months.
.. Days
If under 24 hours
Hours.
.Minutes
13 Usual
Occupation :
Accountant
(Kind of work done during most of working life)
14 Industry
or Business :
Army Base
15 Social Security No. 011-03-2304
16 BIRTHPLACE (City)
(State or country)
New York
17 NAME OF
FATHER
Isadore Schwartz
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Yetta (unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
6
Meretzer Cemetery
Woburn
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
June ..... 12
1963
7 NAME OF
FUNERAL DIRECTOR
Levine Chapel, Inc.
ADDRESS
470 Harvard St., Brookline
Received and filed
JUN 18 1963
19
(Registrar)
PARENTS
21
Informant
Bessie Schwartz
(Address) 18 Dolphin Ave, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was Hed with me BEFORE the burial or transit permit was issued:
(Signature. of Ageat of Board of Health or other)
Health, Office
(Official Designation) (
(Date of Issue of l'ermit)
Learn. 17-1963
662
1
ATE
TH
e
(c) mean ying, ilure, leans mpli- used
ty, 10 2), er- st.
atrib- not minal given
137. ires It or or on and of ysi - type ure.
(Signed)
The Con Litersware, M. D).
CHARLES LIBERMAN
(Address) .
(PRINT OR TYPE SIGNATURE)
WINTHROP, MASS Date.
6/16/
1963
1/2 yrs
Due To (c)
OTHER
SIGNIFICAN Myocardial Infarction
DIABETES MELLITUS
4 Thouths
V/yr.
Was autopsy performed?
10
What test confirmed diagnosis ?
CLINICAL
5 Was disease or injury in any way related to occupation of deceased? to. If so, specify
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED Married
or DIVORCED
10a If married, widowed, or divorced
Bessie ....
Goldbin
HUSBAND of
(Give maiden name of wife in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Cerebral
Hemorrhage
DEATH
3 hrs.
Due To
(b)
Hypertension,
A
2 FULL NAME
Abraham Schwartz
(If nonresident, give city or town and State)
4
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
CANNOT
BE
LEARNED
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.
JUN 1 81963 AN
PLACE OF DEATH
SUFFOLK
(County)
WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
(City or Town making this return)
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Registered No.
115
No.
Winthrop Community Hospital
[(If death occurred in a hospital or institution,
St. ? give its NAME instead of street and number)
2 FULL NAME
GRACE
(First Name)
(Middle Name)
(Last Name)
U. S. War Veteran,
[if so specify WAR)
NO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
107 Bowdoin Street
Winthrop, Massachusetts
St
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years.
1
... months.
20 days. In place of residence.
25
.years ..
.. months .......
.. davs.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June
20,
1963
(Month)
(Day)
(Year)
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.) Cerebro-vascular accident. Fracture of
femur.
5 Accident, suicide, or homicide (specify)
Accident.
Date and hour of injury
May .... 1,
19
63.
Yes.
IF ACCIDENTAL, was injury causally related to the death?
Where did
Injury occur ?
Winthrop, Massachusetts.
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or
public place ?
Home
Manner of
Injury
Accidental fall to floor.
Nature of
Fracture of femur
Injury
While at work ? Was autopsy performed. ....
No.
6 Was d
Michael A. Luongo, M.D.
( Print or Type Name)
(Address) ..... Boston
Date
.....
6/20
19 63
7 Winthrop
Winthrop
DATE OF BURIAL June 24
(City or Town) 1963
8 NAME OF Comment PGaggiano ADDRESS 147 WINTHROP ST Winthrop
Received and filed JUN 2.1 1963 19.
A TRUE COPY ATTEST:
(Registrar)
PARENTS
19 BIRTHPLACE OF FATHER (City) (State or country)
Italy
20 MAIDEN NAME
OF MOTHER
Grazia Rinaldi
21 BIRTHPLACE OF MOTHER (City) (State or country) Italy
22
Frank Persone
Informant (Address) 109 Bowdown St Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Tokah &. Verianne
(Signature of Agent of Board of Health or other)
+1,1763 ×
(Official Designation)
(Date of Issue of Permit)
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
100M -3.62-932695
AGE
Months ............. Days
If under 24 hours
Hours
Minutes
14 Usual
Occupation :
15 Industry 0 Business :
(Kind of work done during most of working life) at Home None
16 Social Security No. ....
Italy
17 BIRTHPLACE (City) (state or country ) 18 NAME OF FATHER Salvatore Mancuso
13 77
2X
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
12 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Leonard Perrone
(Husband's name in full)
9 SEX
Female
10 COLOR
White
PHYSICIAN - IMPORTANT
[(Was deceased a
(a) Residence.
No.
(Usual place of abode)
PERRONE
(MANCUSO)
permit alth
-
(Specify type of place)
(How did injury occur ?)
... , M. D.
Place of Burial or Cremation.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE ERK
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 unrelated to any form of injury. THROP. M
(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. JUN 2 11963.AM
(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.)"
-301
1
PLACE OF DEATH
SUFFOLK (County) WINTHROP. (City or Town) 263 MAIN ST No ... OLIVER
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No. $16
[(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.)
263 MAIN ST
St WINTHROP
MASS
Length of stay: In place of death 5 years.
months
days. In place of residence 5 years
.months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June
21
1960
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
June
19
19.63
to ...
June 21
1969
I last saw h&Malive on
June 19
1965, death is said to
have occurred on the date stated above, at
1 0mm.
INTERVAL
BETWEEN
ONSET AND
DEATH
Due
(b)
ArTherio Sclero SIS
Due To
(c)
ArTherio Sclerotic Heart Disease jump
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
What test confirmed diagnosis
Climaexam
5 Was disease or injury in any way related to occupation of deceased? ? If so, specify
(Signature)
hours E Schaffa
(Address)
19 Ber
23047
WINTHROP
WINTHROP.
l'lace of Burial or Cremation
(City or Town)
DATE OF BURIAL
JUNE 24
1963
7 NAME OF
MAURICE W KIRBY
ADDRESS
WINTHROP
Received and filed
JUN 2 1 1963
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWN MARRIED
11 If married, widowed, or diyorçed
HUSBAND of
MARY
DOYLE
(Give maiden name of wife in full) (or) WIFE of
(Husband's name in full)
12
AGE 79 Years.
.Months ....
.Days
If under 24 hours
Hours
Minutes
13 Usual
RETIRED
WAITER
10 mm Occupation :
(Kind of work done during most of iworking life)
14 Industry
or Business : .
HOTEL
15 Social Security No ....
021-05-29224
16 BIRTHPLACE (City)
FITCHBURG
(State or country )
MASS
17 NAME OF
FATHER
JAMES BROCK
PARENTS
18 BIRTHPLACE OF
FATHER (City)
GLASGOW
(State or country)
SCOTLAND
19 MAIDEN NAME
OF MOTHER
MARY SMITH.
20 BIRTHPLACE OF
MOTHER (City)
(State or country )
ENGLAND.
21 Informant
MRS MARY BROCK
(.Address)
263 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:
(Signature of Agent of Board of Health or other) (?)
Halte Offices
11, 963
(Registrar )|| (Official Designation)
(Date of Issue of Permit)
X V.B. V
permit :alth
ATE
PE SES
2 (c) mean ying, ilure , seans mpli- aused
ty,
a), er- st. trib- ! not minal given
M. D.
(Print or Type Name)
19. 68
6
A TRUE COPY ATTEST:
BROCK
(Was deceased a
U. S. War Veteran,
if so specify WAR).
NO.
(a)
Residence. No ..
(Usual place of abode)
(City or Town making this return)
(City or town and State)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Coronary Thrombosis.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
8
-
/1RULESOF PRACTICE IN-
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 IN 12.1.1963 40 (2) Board of Health physicianf whi cef fy 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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