Town of Winthrop : Record of Deaths 1963, Part 24

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 24


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).


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54


(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.


304


PLACE OF DELIVERY No.


10M-6-62-933404 X Suffolkz County) Winthrop 1 (City or Town


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)


To be filed for buriaf permit with Board of Health or its Agent.


Registered No.


117


(If death occurred in a hospital or institution, give its NAME instead of street and number)


3 DATE OF


DELIVERY


y June 24 1963


Month )


(Day)


(Year)


7 IF MULTIPLE BIRTH, BORN :


1st


.2nd


3rd


FATHER


8


FULL


NAME


Angela Santoro


14


MAIDEN NAME


Ida


MOTHER Santoro"


PRESENT NAME


Ida Lauranos


9


RESIDENCE, NO.


178 Bernin CarSTREET


CITY OR TOWN


EAST Bs Con STATE Man


RESIDENCE, NO. 178 Bennington Str. CITY OR TOWN


EastBesten


STATE.


10 CO


Echte


11 AGE AT TIME OF


THIS DELIVERY


48 (Years)


16 COLOR OR Ket RACE.


17 AGE AT TIME OF THIS DELIVERY 37


(Years)


12 PLACE OF


BIRTH


EBaton


(City or Town)


Mars


(State or country)


18 PLACE OF


BIRTH


E, Boston


Mass


(City or Town)


(State or country)


13 OCCUPATION Clerk, U.S. POT office


19


INFORMANT


Ida San Toro


20 PREVIOUS DELIVERIES TO MOTHER


(Do not include this fetus)


6


(a) How many children are


now living?


6


(b) How many children were


born alive but are now


dead ?


more


(c) How many previous fetal deaths of ANY gestation age? nona


21 LENGTH OF


PREGNANCY


completed weeks


17


22 Weight


OF FETUS


(or


4/2Oz.


Grams)


23 WHEN DID FETUS DIE?


Before


Labor


During Labor


or Delivery


Unknown


v


24 AUTOPSY


Yes


No


25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a)


Unknown


Due To (b) Due To (c)


OTHER SIGNIFICANT


CONDITIONS


Mone


26


Holy CROSS


Place of Burial or Cremation


DATE OF BURIAL


6/26


MAIDEN


(City or Town)


1963


27


NAME OF ANTHONY Patsy


FUNERAL DIRECTOR


Rapino


ADDRESS


& Chelsea ST & Boton


Received and filed


JUN 27 1963


19


( Registrar )


A TRUE COPY ATTEST :


I HEREBY CERTIFY that this delivery occurred on the date stated above at 1232 pm, and product of conception was not a live birth.


Signature of Attending Physician or Medical Examiner : Louis ESchaffe M.D.


Address


Louis E Schraffa (PRINT OR TYPE NAME) 19Bennington Date fre 24,63


I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued : Ralphe E. Sincanin (Signature of Agent of Board of Health or other )


(Official Designation )


96.0.


June 26, 1963X


(Date of Issue of Permit)


ng OF EATH ter one each b) )


ternal ausing h (do such Ilbirth rity.) r ma- itions. h gave bove stating lying


of fetus which ontrib- fetal in so known. related given


4 SEX


Male./


... Female ...... Undetermined


5 COLOR (if


determined).


6 THIS BIRTH (Check one)


Single.


Twin


Triplet


Balbay Santoro


2 NAME OF FETUS


(if given)


Winthrop Comment Aspecten St.


STREET


RACE ..


FETAL DEATH


EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48, ACTS OF 1960.


Section 2A. "Examination of records and returns of illegitimate births, or abnormal sex births, or fetal deaths, .. . shall not be permitted except ... ".


Section 9A. When a child is born dead, after a period of gestation of not less than twenty weeks, and in the fetus there is no attempt at /respiration, no action of heart and no movement of voluntary muscle, the physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.


Section 12. No birth record of a child born out of wedlock or of a child of abnormal sex, and no record of fetal death shall so be transmitted to any other city or town."


Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.


X Suffolk (County) 1 Winthrop (City or Town)


REVERE 7-3-63


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.


Registered No.


$(If death occurred in a hospital or institution,, St. { give its NAME instead of street and number) No ...


104 Highland Ave . PHYSICIAN - IMPORTANT


(Was deceased a


U. S. War Veteran,


if so specify WAR)


No


Revère


(a) Residence. No. (Usual place of abode)


135 CRYSTAL


Ave.,


St.


(If nonresident, give city or town and State)


Length of stay: In place of death ............ years. .months. days. In place of residence 58 years months. .. days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


JUNE


25


(Day)


1963 (Year)


4 I HEREBY CERTIFY,


That I attended deceased from


MARCH 10


19.


53


to ....


JUNE


25


19.


63


I last saw h.Malive on


JUNE 21


196 3, death is said to


have occurred on the date stated above, at


3 40 Am.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


CARCINOMA OF


(a)


PROSTATE GLAND


Due To (b)


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


NO


What test confirmed diagnosis ?.


CLINICAL


NO


5 Was disease or injury in any way related to occupation of deceased? If so, specify.


(Signed)


(Ad 120 CRESSENT-AVE Dat JUNE 25 1963


6


Woodlawn Place of Burial or Cremation (City or Town)


DATE OF BURIAL.


6-27-


163


7 NAME OF


FUNERAL DIRECTOR ARTHUR


S. PORCELLA


ADDRESS.


876 Loin Throp Are-Rerere


Received and filed.


JUN 27 1963


19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


MALE White


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED


Widowed


10a If married, widowed, or divorced


HUSBAND of.


AgNes


Dotty


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE 81


Years


Months.


Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


RETired - CarpenTER


(Kind of work done during most of working life)


14 Industry


or Business:


15 Social Security No.


022-16-7063


16 BIRTHPLACE (City)_


(State or country)


New York


N.4


17 NAME OF


FATHER


George


Keeler


18 BIRTHPLACE OF


FATHER


(City) ..


ThrogNeck


(State or country)


New york


RUE-


20 BIRTIIPLACE OF


MOTHER (City) ..


(State or country)


IV. 4


21 Charles KeelER


Informant (Address) 135 CRYSTAL Are Revere I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Nulfch / Jermann (3) (Signature of Agent of Board of Health or other)


Health office


June- 27,1963


(Official Designation)


(Date of Issue of Permit)


X


A


TE


TH


c)


can ng, tre, ans pli- sed


0


-


t.


rib- not inal ven


137, Ires t or or on


100M-11-55-916145


PLACE OF DEATH


2 FULL NAME.


Mount's Convalescent Home HENRY J. Keeler


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(Month)


INTERVAL BETWEEN ONSET AND DEATH 4 YRS


PARENTS


EverETT


19 MAIDEN NAME


Joseph & Palermo


M. D.


OF MOTHER


Emily J. TURNER


EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE


RETURN OF CERTIFICATES OF DEATH


A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased. his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.


A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- te n, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Chap. 46, Sec. 10.


No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another. or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose. the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the


death certificate contains a recital, as required by section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114. Sec. 45, G. L., (Tercentenary Edition).


Medical examiners shall make examination upon the view of the dead bodies of persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. ... - General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.


No undertaker or other persons shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made.


Chap. 114, Sec. 46, G. L., (Tercentenary Edition).


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the follow- ing 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.


(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 occupation. the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cauld of Death Physicians: see explanatory instructions on face side of standard tirtiicate of death !!


Statement of Occupation .- Precise statement of occupation is very import- ant, 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. Children 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.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING .


ORGANIZATION AND OUTFIT


SERVICE NUMBER


......


DIA


1


Winthrop


(City or Town)


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.


119


Registered No.


§(If death occurred in a hospital or institution,


St. ¿ give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


(Was deceased a


U. S. War Veteran,


(if so specify WAR)


no


(a) Residence. No.


80 ... Sagamore ... St


(Usual place of abode)


St


Revere Mass


(If nonresident, give city or town and State)


Length of stay: In place of death.


............. years.


.months ...


20 .. days. In place of residence.


30


.. years.


.months.


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


10 SINGLE


(write the word)


8 SEX


Male


9 COLORA


White


MARRIED


WIDOWERBARREL


or DIVORCED


4 I HEREBY


20


19 63


to


une


27


19. 63


List saw him.alive on


.


Ame27, 1963, death is said to


have occurred on the date stated above, at


10:50 am.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Coronary Thrombosis


Due To


(b)


Duodenal Weer.


Due To gastroenterostouTweets ENTEROS TOMY


(c)


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed? What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


(Signed)


John H Csanda


.. ,


M. 1).


(Address)


PRINT OR TYPE SIGNATURE) Winthrop Mass ... DateJune22163


Puritan Lawn Peabody


Place of Burial or Cremation


(City or Town)


DATE OF BURI 1


July 1,,1963


19


7 NAME OF


FUNERAL DIRECTORY . Vincent Murray


ADDRESS Revere


Received and filed


JUN 28 1963


19


(Registrar)


20 day


13 Usual


Occupation :


(Khl & R&kTore during most of working life)


14 Industry


or Business :


Edison Co.,


15 Social Security No.


012 07 4861


16 BIRTHPLACE (City) (State or country) Boston Mass.


17 NAME OF


FATHER


wichael "elley


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Ireland


19 MAIDEN NAME


OF MOTHER


Mary Ryan


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Ireland


21 Elizabeth nelley


Informant


(Address)


80 Sagamore St. Revere


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burjal or transit permit was issued: Rueph & Seriam (B) (Signature of Agent.of Board of Ilealth or other)


Health officer


June 28, 1963


(Official Designation)


(Date of łySue of Permit)


X


IS


ICATE


CATH r ne ch 1 (c) mean dying, failure, means ompli- caused


-


any, € to (a), tder- last. ontrib- ut not ·rminal given


r 137. Quires int or e or h on s, and ts of Physi- type ature.


26662


PLACE OF DEATH


REVERE


Suffolk (County)


PINSE PETIT


No. Winthrop Community Hospital


2 FULL NAME


George Kelley


(If deceased is a married, widowed or divorced woman, give also maiden name.)


3 DATE OF


DEATH


June


27


1963


Month)


(Day)


(Year)


CERTIF


That I attended deceased from


10a If married, widowed, or divorced


HUSBAND of


Elizabeth Burke


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


INTERVAL


BETWEEN


ONSET AND


DEATH


2-tis.


12


AGE


Months.


Days


If under 24 hours


Hours ..........


.Minutes


PARENTS


John CRANDON


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 !! gingrych deaths only as those of persons to whom they have given beddddfdare duringaflastillness 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.


×


PLACE OF DEATH


Suffolk (County)


Winthrop (City or Town)


No .... 24 Tileston Rd.


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)


[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)


2 FULL NAME.


Raffaele Famiglietti


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No ...


24 Tileston Road


(Usual place of abode)


St


Winthrop


(If nonresident, give city or town and State)


Length of stay: In place of death + years months.days. In place of residence.


16 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)


widowed


11 If married, widowed, or divorced


Antonetta .... Salerno


HUSBAND of


(or) WIFE


(Husband's name in full)


12


82


1


12


AGE


Years.


Months.


Days


If under 24 hours


.Hours.


Minutes


13 Usual


Occupation :


Retired .... Storekeeper


(Kind of work done during most working life)


14 Industry


or Business:


Retail Grocery


15 Social Security No 033-26-4468


16 BIRTHPLACE (City) ..... Gesualdo


(State or country)


Italy


17 NAME OF


FATHER


Raffaele Famiglietti


1


(Signature)


Varen La Saliva


M. D.


marion 0


(Print or Type Name)


(Address)


241 Manerabal


7 ......


Date June 24 1963


6


St. Michael Cemetery, Boston


Place of l'urial or Cremation


(City or Town)


DATE OF BURIAL


July 2,


19.63


7 NAME OF


FUNERAL DIRECTOR


Ernest P. Caggiano


147 Winthrop St., Winthrop


ADDRESS


Received and filed


JUL 1 1963


19


Dr. Joseph A. Famiglietti


21 Informant


( Address)


227 Court Rd., Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E Jejedina (3)


(Signature -of Agent of Board of Health or other)


Health Ofkain


Lucky 1, 1963


( Registrar) || (Official Designation)


(Date of Issue of Permit)


RUAV


A TRUE COPY ATTEST:


H


TE


ES


)


ean ng, ire, ans pli- sed


:


rib- not nal ven


301


permit AIth


1


(b)


Due To


Chronic Bronchiestavis


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


What test confirmed diagnosis ?


INTERVAL BETWEEN ONSET AND DEATH 2 hre


DEATH WAS CAUSED BY: IMMEDIATE CAUSE Car-salmonale


(a)


3 DATE OF


DEATH


Danse


28 1963.


(Year)


&Month)


(Day)


4 IHEREBY CERTIFY,


That I attended deceased from


may 19. to ........


60


5.8


1963


I last saw herzalive on


Dorme


28


13


death is said to


have occurred on the date stated above, at


1:30 $


(Give maiden name of wife in full)


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Italy


19 MAIDEN NAME


OF MOTHER


Angela Maria


20 BIRTHPLACE OF MOTHER (City) (State or country) Italy


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


PHYSICIAN - IMPORTANT


) (Was deceased a


U. S. War Veteran,


(if so specify WAR).


no


Registered No.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


RECEIVED


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.




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