Town of Winthrop : Record of Deaths 1963, Part 23

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 23


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


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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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