USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 28
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(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)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
137
(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 ..
18 Cottage Ave
St
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months ..
1.Gays. In place of residence .. 20years.
... months ...
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
Match, 1962
to ..
July
15
63
I last saw h.CYalive on 14, 1963, death is said to
have occurred on the date stated above, at 6:10A. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Career of Pancreas
Due To
(b)
Due To (c)
OTHER
Status post hysterectomy ctos,
CONDITIONS
Was autopsy performed ?
Yes
What test confirmed diagnosis? Clinical, surgical.
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
Date.
7/15/1963
.S.t ...... Patricks, .... Lowell ...... Mas.s.
0
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
July 17, 1963
19
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS
Winthrop, Mass.
Received and filed
JUL 15 1963
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWERSingle
DIVORCED
UNKNOWN
11 If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AG 45
Years.
Months ...
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
SchoolTeacher
(Kind of work done during most working life)
14 Industry
or Business :.
Education
15 Social Security No.
16 BIRTHPLACE (City) (State or country) Holyoke ..
Mass
PARENTS
17 NAME OF FATHER John ODonnell
18 BIRTHPLACE OF
FATHER (City) ..
Holyoke
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Anastasia Downing
20 BIRTHPLACE OF
MOTHER (City)
Lowell
(State or country)
Mass
21 Informant
Esther O'Donnell
(Address)
18 Cottage Ave,, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph 5. Siria
(Signature of Agent of Board of Health or other) (NP) Health Officer July 15, 1963
(Date of Issue of Permit)
THE.V
1
I permit ealth
ATE
E ES
c)
sean ling, sare eans spli- used
y, to
trib- not inal iven
-301
(City or Town making this return)
Winthrop Community Hospital No.
2 FULL NAME. Kathleen D. O'Donnell
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Usual place of abode)
15
1963
That I attended deceased from
INTERVAL BETWEEN ONSET AND DEATH 6 anos
A TRUE COPY ATTEST:
(Registrar) (Official Designation)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
[THROP
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice: JUL 20103 MI
(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.
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
Registered No.
138
2 FULL NAME
Alfred H. Queenan.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
47 Loring Rd.
Winthrop
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
1
.. years.
4
months
3
days. In place of residence .............. years ..
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED Widowed
WIDOWED
or DIVORCED
4 I HEREBY CERTIFY, That I attended deceased from
Sept. 1956
65
to
14416
19.
I last saw h ..... Yafive on
July 16/ 1963, death is said to
have occurred on the date stated above, at
11:15Pm.
INTERVAL
BETWEEN
ONSET ANO
11 IF STILLBORN, enter that fact here.
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cerebral Hemorrhage ....
Due To typertension and cerebral (b)
Arteriosclerosis,
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
None.
Was autopsy performed?
NO
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased? No. If so, specify ....
(Signed)
Charles Liberman, M.
I. D.
CHARLES LIBERMAN
(PRINT OR TYPE SIGNATURE)
(Address) WINTHROP, MASS Date.
1/16/1963
Cambridge Catholic Cambridge
Piace of Burial or Cremation DATE OF BURIAL
July Igy or Town) 19
1.63
7 NAME OF
FUNERAL
Frederick J. Magrath 325 Chelsea St. East Boston. ADDRESS
Received and filed JUL 18 1963
(Registrar)
PARENTS
18 BIRTHPLACE OF
East Boston,
FATHER (City)
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Catherine Mccarthy
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Philadelphia
Penn.
21 Mildred Queenan.
Informant
(Address)
47 Loring Rd. Winthrop
I IIEREBY 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) (3)
Health Officer
July 13, 1963
(Official Designation)
(Date of Issue of Permit)
1 x+ V
S
ICATE
ATH
r ne ch (c) mean dying, ailure, means om pli- caused
any, e to (a), der- last.
ontrib- ut not rminal given
r 137. quires int or le or h on s, and cts of Physi- r type ature.
$686
PLACE OF DEATH
SUFFOLK
(County)
No.
Mayflower Nursing Home
[(If death occurred in a hospital or institution,
St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
{(Was deceased a
NO
{ U. S. War Veteran,
[if so specify WAR)
(a) Residence. No. ( Usual place of abode)
3 DATE OF
DEATH
July
16
1963
(Month)
(Day)
(Year)
10a If married, widowed, or diANNA B. Burns ..
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
12
AGE ..
Years.
Months ...
.Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Shipfitter
(Kind of work done during most of working life)
14 Industry
or Business :
Retired
B. Naval Yard
15 Social Security No.
C.N. B. L.
16 BIRTHPLACE (City)
(State or country)
East Boston
Mass.
17 NAME OF
FATHER
John Queenan
DEATH
IWR.
77
4yrs
6
To be filed for burial permit with Board of Health or its Agent.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
HRUR
JUL 1 81963 FH
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.
JUL 1 81003 EM
R-301
permit alth
CATE
PE SES
e h (c)
mean lying, sluTe, neans mpli- aused
ny, 10 a), ter- ast.
ntrib- ! no! minal given
Was autopsy performed ?
What test confirmed diagnos!
Clinical, Surgical Pathdag
5 Was disease or injury in any way related to occupation of deceased? f If so, specify ...
No
(Signature)
Charles
Libe man,
M. D.
CHARLES LIBERMAN
(Print or Type Name)
(Address WINTHROP MASS Date.
7/19/1963
6
WINTHROP
NINTHRCI?
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
JULY 20
1965
7 NAME OF
FUNERAL DIRECTOR
MAURICE UN TIPBY
ADDRESS
WINTHROP.
JUL 19 1963
19
( Registrar )
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
WHITE
10 SINGLE
MARRIED
WIDOWED
DIVORCED
(write the word)
MARRIED
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
GALLANTE 19
(or) WIFE of
JOHNY.
(Husband's name in full)
12
41
. Months ..
.Days
Occupation :
(Kind of work done during most of iworking life)
14 Industry
or Business :.
CITY OF BOSTON,
15 Social Security No.
16 BIRTHPLACE (City)
(State or country }
MASS.
17 NAME OF
FATHER SALVATORE BATTAGLIA.
18 BIRTHPLACE OF
FATHER (City) .....
ITALY
(State or country)
19 MAIDEN NAME
OF MOTHER FRANCES, FISSICHELLA
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
ITALY
21 Informant
JOHN J GALLAHER
(Address)
37 CLIFF AVE WINTHROP.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Patch 6°.
(Signature of Agent of Board of Health or other)
Health Officer
July 19.1963
(Official Designation) (Date of Issue of Permit)"
4
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)
BAY VIEW NURSING HOME STURGES 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.
HELEN DI BATTAGLIA) GALLAGHER
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
NO
37 CLIFF AVE
(Usual place of abode)
St WINTHROP
(City or town and State)
Length of stay: In place of death ........ years ......... months Ce days. In place of residence.
8
years.
months
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July
17
1963
(Month)
(Đay)
(Year)
4 I HEREBY CERTIFY> That I attended deceased, from
Sept
1961
to ..
1414
19.,
1963
17
I last saw /He.Talive on
July 17, 1963, death is said to
have occurred on the date stated above, at
11:15 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cancer of Beast
INTERVAL
BETWEEN
ONSET AND
DEATH
2/2 yrs
Due To (b)
Due To (c)
OTHER
Carcinomatosis to
SIGNIFICANT
CONDITIONS
Lung
NO
1/2 yrs
BOSTON
PARENTS
Received and filed
John allach
1
Registered No.
139
(a) · Residence. No ..
FEMALE
If under 24 hours
Hours
Minutes
13 Usual
SOCIAL WORKER
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 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.
JUL 101003 7:
R-301
1
PLACE OF DEATH
Suffolk Four (County) Winthropp (City or Town)/
REVERZ 89-5-8
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. 140
rial permit Health nt. IS
ICATE
YPE USES 1
ne ch (c)
mean dying, failure, means compli- caused
any, e to (a), der- last. contrib- ut not erminal given
-
Due
(c)
arteriosCLERutic heart disease
OTHER
SIGNIFICANT
CONDITIONS
CARDIAC FAILURE
1 day
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature) andre Catino, M. D. ANDREW CATINO M.D. (Print or Type Name) (Address) 603BROADWAY Date Lub 18 963
Revere Holy Cross Malder 6
Place of Burialof Cremation (City or Town)
DATE OF BURIAL
july 19
1963
7 NAME OF
FUNERAL DIRECTOR
Iamminis Sements
224 North st Boston
ADDRESS
..
JUL 18 1963
Received and filed 19
8 SEX
Familie
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Widowed
11 1f married, widowed, or divorced HUSBAND of
(or) WIFE of.
achille Mauceri
(Husband's name in full)
12
83 Years.
Months.
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation
House Wife
(Kind of work done during most of working life)
14 Industry
or Business.
OWN home
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Italy
17 NAME OF
FATHER
Lorenzo Pusti
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy.
19 MAIDEN NAME
OF MOTHER
Giuseppina Malica
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Joseph Maucerison
(Address)
79 Pitcairn st Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Rarak Sirianni
(Signature of Agent of Board of Health or other) Health Officer
( N+3 )
July 18, 1963
(Date of Issue of Permit)
- X
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
(Day)
(Year)
4 2
HEREBY CERTIFY,
July 13. 1962
to nal
17
That I attended deceased from 19.63
last say h.Cgalive on
have occurred on the date stated above, at .. 10 P. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
CARdiAC DeCOMPENSATION
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
2day
Due To (b)
2.0
ly 17-1963
Length of stay: In place of death .......... years.
Corrandina Mauceri
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
79 Pitcairn
(a) Residence. No ..
(Usual place of abode)
10
.months.
days. In place of residence.
3 years.
.months.
... days.
Ridere Mars
.St.
(City or town and State)
s NA
[(If death occurred in a hospital or institution,
May Flower Nursing Hangi No
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(write the word)
196 3 death is said to
/Give maiden name of, wife in full)
PARENTS
21 Informant
( Registrar)| (Official Designation)
53
-
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
1
6
19
ROP
JUL 1 81963 Při
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.
R-301
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.
141
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
Beatrice Macfarland
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
46 Harbor View Ave. Winthrop
St
(Usual place of abode)
Length of stay: In place of death .......... years .......... months.
2days. In place of residence .... .... years.
........ months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED Widowed
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE o
Edwin Curtis Macfarland
(Husband's name in full)
12
AGE .. 68Years ... 6 ..
.Months .... 1.2Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Hotel .... Clerk
(Kind of work done during most working life)
14 Industry
or Business :
Hotel Services
15 Social Security No 030 03 5630
16 BIRTHPLACE (City).Marlboro, .... Mass. (State or country )
17 NAME OF
FATHER
Stephen E. Simmons
18 BIRTHPLACE OF
FATHER (City)
Framingham, Mass.
(State or country)
19 MAIDEN NAME
OF MOTHER
Minnie E. Spofford
20 BIRTHPLACE OF
MOTHER (City)
Unknown Wayland
(State or country)
Mass.
21 Informant
Edwin.E. Macfarland Ison)
( Address)
46 Harbor View Ave. Winthrop, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Pulph
(Signature of Agent of Board of Health or other)
Werethe officer
Julia 19, 1963
( NP3 )
(Official Designation)
(Date of Issue of Permit)
-
V
rial permit Health nt. NS FICATE
YPE USES H
er one ach d (c)
t mean dying, failure, means compli- caused
any, se to (a), inder- last.
(c)
RHEUMATIC HEART DISEASE
50YRS
OTHER
SIGNIFICANT
CONDITIONS
NONE
Was autopsy performed?
No
What test confirmed diagnosis? EKG.X-RAY
5 Was disease or injury in any way related to occupation of deceased? No If so, specify
(Signature)
Dorthy Cheney appleton
M. D.
DOROTHY CHENEY APPLETON
(Print or Type Name)
(Address)
197 Woodside AVE Date
7/18
19 63
WINTHROP, MAJS
6
.Woodlawn .... Crematory
Everett Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
July22 1963
19
7 NAME OF
FUNERAL DIRECTOR
Alfred B. Marsh
ADDRESS
174 Winthrop St. Winthrop
Received and filed
JUL 19 1963
19
(Registrar)
A TRUE COPY ATTEST:
382
PLACE OF DEATH
Suffolk (County)
No .. Winthrop Community Hospital
2 FULL NAME
3 DATE OF
DEATH
JULY
18
1963
(Month) (Day)
(Year)
41HEREBY CERTIFY , That I attended deceased from JULY 16 63 to. JULY 18 19 63
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