Town of Winthrop : Record of Deaths 1963, Part 35

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 35


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


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.)"


1


PLACE OF DEATH


SUFFOLK


REVER 2.


$12.63


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD


CERTIFICATE OF DEATH


Registered No. 173


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.)


57 WINTHROP PARKWAY


St.


Length of stay: In place of death .years months 30 days. In place of residence


(If nonresident, give city or town and State)


9


.years.


.. months


days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


Sept.


8


1963


(Month) (Day)


(Year)


8 SEX


FEMALE


9 COLOR


WHITE


10 SINGLE


(write the word)


MARRIED


MARRIED


WIDOWED


or DIVORCED


10a If married, widowed, or divorced


HUSBAND of


PETER RUSSO


(Giye maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


63


AGE


Years


7


Months


14Days


If under 24 hours


.. Hours ...... Minutes


13 Usual


Occupation :


HOUSEWIFE


(Kind of work done during most of working life)


14 Industry


or Business:


AT HOME


15 Social Security No .....


024 05 5592


16 BIRTHPLACE (City)


(State or country)


ITALY


17 NAME OF


FATHER


JOSEPH MAZZARELLA


18 BIRTHPLACE OF


FATHER (City)


(State or country)


ITALY


19 MAIDEN NAME


OF MOTHER


LAURA CAPUCCI


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


ITALY


21 PETER RUSSO (HUSBAND)


Informant


(Address)


57 WINTHROP PARKWAY, REVERE, MASS.


7 NAME OF


FUNERAL DIRECTOR


LAWRENCE BRUNO


291 REVERE STREET, REVERE, MASS.


ADDRESS


Received and filed SEP 9 1963 19


(Registrar)


up


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed?


NO


What test confirmed diagnosis?


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


(Signed)


Ineple Aregone


M. D.


194 Washing Produc 9/9


(Address)


163


HOLY CROSS CEMETERY , MALDEN, MASS. 6


Place of Burial or Cremation


DATE OF BURIAL


SEPT. 11,


(City or Town)


1963


19


PARENTS


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Palak 6. rianne (Signature of Agent of Board of Health or other) health Prices Just. 9.1963


(Official Designation)


(Date of Issue of Permit)


-THIS IS A VENT RECORD. se only APPROVED ink or black riter ribbon.


RUCTIONS FOR . CERTIFICATE giving OF DEATH not enter than one for each (b) and (c)


does not mean de of dying, heart failure, etc. It means se. or compli- which caused


ons, if any, gave rise to cause the cause


(a), under- last.


itions contrib -- > death but not o the terminal condition given


Chapter 137, 1954, requires ns to print or e cause or of death on ertificates. HAP. 46, 55 9 & AP. 114 $$ 45, HAP. 38$6.)


10.58.923866


(County) WINTHROP


(City or Town)


WINTHROP COMMUNITY HOSP,


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


No. ANNA RUSSO (NEE MAZZARELLA)


PHYSICIAN - IMPORTANT


(Was deceased a


U. S. War Veteran,


NO


REVERE


if


specify WAR)


4 I HEREBY CERTIFY,


June, 1961


to ..


Sept. 8


That I attended deceased from


63


I last saw helalive on


Sepr. 7


19 63, death is said to


have occurred on the date stated above, at 11:10 Am.


INTERVAL BETWEEN ONSET AND


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Cerebro - Vascular


(a)


hemorrhage


(b) Due To terioscleroses glu


Due To


Dubeles Mellitus


(c)


DEATH


72 ks


PERSONAL AND STATISTICAL PARTICULARS


(a) Residence.


No.


(Usual place of abode)


MR-301A


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


HROP


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 @as of persons to whom they have given bedside care during a last illness from disease unrelated 03 th 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 Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate 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.


X SUFFOLKT (County) WINTHROP. (City or Town) No. 114 LINCOLN ST


CENSE PETIT


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.


174


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


2 FULL NAME.


MARGARET A (TAYLOR)


(1f deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No.


114 LINCOLN ST


St.


(If nonresident, give city or town and State)


Length of stay: In place of death /1 years.


.. months.


.. days. In place of residence.


11


.years ...


months ..


.days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


Sept.


10


1963


DEATH


(Month)


(Day)


(Year)


4 1 HEREBY CERTIFY, That I attended deceased from


19


to.


19


I last saw h ........ alive on 19. ., death is said to


have occurred on the date stated above, at


8:00 P.m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Death presumably due


INTERVAL BETWEEN ONSET AND DEATH


Due


to natural causes.


(b)


Due To


Winthrop Board of Health


(c)


Charles Liberan Min


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)


M. D.


CHARLES


LIBERMAN


(PRINT OR TYPE SIGNATURE)


9/12/ 1963


6


HOLY CROSS


MALDEN


Place of Burial or Cremation


DATE OF BURIAL


SEPT


13


(City or Town)


7 NAME OF


FUNERAL DIRECTOR


MAURICE W KIRBY


WINTHROP


ADDRESS


Received and filed SEP 13 1963 19.


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


FEMALE


9 COLOR


WHITE


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCENIDOLLED


10a If married, widowed, or divorced HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


EDWARD & BURNS


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AG


87


Months ..


.Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


HOME MANER


(Kind of work done during most of working life)


14 Industry


or Business :


HOME


15 Social Security No.


EAST BOSTON


16 BIRTHPLACE (City)


(State or country)


MASS


17 NAME OF


FATHER


JOHN TAYLOR


18 BIRTHPLACE OF


FATHER (City)


(State or country)


IRELAND


19 MAIDEN NAME


OF MOTHER


MARY J BROGAN


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


NIAS CLARE NI SCOBORIA


21


Informant


(Address)


114 LINCOLN SI WINTHROP


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph 6 Sirianni (S) (Signature of Agent of Board of Health or other) Hereth officer Lebt 13.1963


(Official Designation))


(Date of Issue of Permit)


-59-925686


PLACE OF DEATH


R-301A 1


in


UCTIONS OR CERTIFICATE


giving OF DEATH t enter than one for each b) and (c)


es not mean of dying, seart failure, tc. It means , or compli- hich caused


ns, if any, ave rise to cause (a), the under- ause last.


tions contrib- eath but not the terminal ndition given


Chapter 137, 54. requires 1 to print or : cause or f death on tificates, and 48, Acts of uires Physi- print or type er signature.


Registered No.


PHYSICIAN - IMPORTANT


BURNS


[(Was deceased a


{U. S. War Veteran,


{if so specify WAR)


NO


(Usual place of abode)


PARENTS


ENGLAND


(Address)


WINTHROP, MASS Date.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


11.12 1 il


RI


i .


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the obser @00 1031963 AM 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-301A 1


PLACE OF DEATH


(County)


Chelsea 9-27- 63


The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD


CERTIFICATE OF DEATH


Registered No.


175


2 FULL NAME


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


( Kear ) {if so specify WAR)


(a) Residence. No.


(Usual place of abode)


Length of stay: In place of death.


2


.years. 5 months.


days. In place of residence years months ... .days.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWED Widowed or DIVORCENY


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


Philip ..... Greenspan


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


71


12


AGE


Years.


Months ....


Days


If under 24 hours


Hours ..


Minutes


13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business :


at ...... home


15 Social Security No.


16 BIRTHPLACE (City)


(State or country)


Rüssiä


17 NAME OF


FATHER


Zelig Oxman


18 BIRTHPLACE OF FATHER (City) (State or country)


Russia


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


(Signed) Frederick Orinsteen M. D. Frederick OrNsteen (PRINT QR TYPE SIGNATURE) 131 washington Ave (Address) 9/13 10 63 Date


6


BABKUKHO Cremation Oak Hill


(City or Town)


DATE OF BURIAL . September 15. 1963 .19.


7 NAME OF


FUNERAL DIRECTOR .Benjamin .... Birnbach


ADDRESS TO Washington St.Dorchester


Received and filed SEP 16 1963 19


(Registrar)


PARENTS


19 MAIDEN NAME OF MOTHER Rebecca-Cannot be lear


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


Russia


21 Informant Benny Greenspan (son)


(Address) 677 Morton St., Mattapan


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) (1+-+3)


Thatthe Office


96 3


4, .....


UCTIONS OR CERTIFICATE


giving OF DEATH


t enter than one for each b) and (c)


es not mean of dying, eart failure, tc. It means , or compli- hich caused


ns, if any, ave rise to ause (a), the under- ause last.


tions contrib- eath but nat the terminal ndition given


Chapter 137. 54. requires s to print or cause or f death on tificates, and 48, Acts of uires Physi- print or type er signature.


-59-925686


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


September 13, 1963


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY


That I attended deceased from


April 10th, 1963


to Sept. 13th


63


I last saw het alive on


Sept 13,


,63


death is said to


have occurred on the date stated above, at 4 15 p.m. INTERVAL BETWEEN ONSET AND


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


Acute Cardiac Decompen-


(a)


SATION 2 PULMONAry EdAnd


DEATH 5 hrs


Due To Chr. Arterio Sclerotic Heart Disense (b)


4 yrs.


Due To (c)


OTHER SIGNIFICANT CONDITIONS


Cerebral Atrophy


Was autopsy performed? What test confirmed diagnosis ?


Chelsea mass


Peabody


Winthrop (City or Town)


's Convalescent


Mount ..... Nxxxxxx Home Inc.


No. Pase Green SpanROSE GREENSPAN


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


PHYSICIAN - IMPORTANT


GIS. War Veteran, NO


227 Broadway


St. Chelsea., Ma ss.


(If nonresident, give city or town and State)


20


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


X Suffolk


(Official Designation) (Date of Issue of Permit)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING ORGANIZATION AND OUTFIT


SERVICE NUMBER


6


ROPRULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice ; (1) Attending PhysicalOAf 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.


ORM R-301


for burial permit ard of Health ts Agent. UCTIONS FOR CERTIFICATE


OR TYPE OR CAUSES DEATH ot enter than one for each (b) and (c)


Does not mean e of dying, heart failure, etc. It means e, or compli- which caused


ons, if any, gave rise to cause (a), the under- cause last.


itions contrib- death but not the terminal ondition given C.


PLACE OF DEATH


Suffolk


(County)


Winthrop


(City or Town)


No


214 Somerset Ave ..


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


PHYSICIAN - IMPORTANT


2 FULL NAME


Miriam F. Macken


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


(a)


Residence. No ..


214 Somerset Ave


(Usual place of abode)


... St


(If nonresident, give city or town and State)


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


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


September 14, 1963


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY , That I attended deceased from


Sept


19.


62


to


Sept. 14


1963


I last saw helalive on


9/13


1944 death is said to


have occurred on the date stated above, at 4155 A.m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


Cancer


of


Breast.


2yrs,


Due


To with generalized


(b)


metastasis


Due To


(c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


NO


What test confirmed diagnosis


Clinical Pathological


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 9/14/1963


6


Winthrop Winthrop ...


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


September 17


19


63


7 NAME OF


FUNERAL DIRECTOR


Arthur J. O'Maley


ADDRESS Winthrop, Mass.


Received and filed


SEP 16 1963


19


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Female


9 COLOR


White


10 SINGLE


MARRIED


WIDOWED Married


DIVORCED


UNKNOWN


11 If married, widowed, or divorced HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of ..


James T. Macken


(Husband's name in full)


12


AG: 45


Years


.Months .....


... Days


If under 24 hours


Hours ......


Minutes


13 Usual


Occupation :


Housewife.


14 Industry


or Business :


Own Home


15 Social Security No ..


16 BIRTHPLACE (City) (State or country ) Mass


Medford


17 NAME OF FATHER Frederick Wholley


18 BIRTHPLACE OF


FATHER (City)


Boston


(State or country)


Mass


19 MAIDEN NAME


OF MOTHER


Mary McCormack


20 BIRTHPLACE OF


Boston


MOTHER (City)


(State or country )


Mass


21 Informant James .... T. Macken ( Address)


214 Somerset Ave., 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)


Health Officer


Sept 16.1963


-1


A TRUE COPY ATTEST:


(Registrar) | (Official Designation)


(Date of Issue of Permit)


›2-932382


I


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.


176


(Was deceased a


U. S. War Veteran,


if so specify WAR).


No


(write the word)


INTERVAL BETWEEN ONSET AND DEATH


(Kind of work done during most working life)


PARENTS


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 eccupa- 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, Co hotel, etc. For a person who had no occupation whatever write none. IN


TO:


i 12


CLERK


6 5


HI


SEP 1 61963 AM


X


PLACE OF DEATH


Plymouth


(County)


I


Bridgewater


No.


M.C.I. Bridgewater, Mass.


S(If death occurred in a hospital or institution,


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


2 FULL NAME.


Francis A. Roberts


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


74 Nead


St


(If nonresident, give city or town and State)


Length of stay: In place of death ......... years months 4


days. In place of residence ......... years .......... months .......... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


W


10 SINGLE


MARRIED


(write the word)


(Month)


(Day)


(Year)


4 I HEREBY CERTIF


Sept. 11,63


to


Sept ..


14


That I attended deceased from


63


I last saw h .. ]Move on


Sept. 14


19.


6 death is said to


have occurred on the date stated above, at


3.0


... m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


INTERVAL


BETWEEN


DNSET AND


DEATH


dys


11 If married, widowed, or divorced


HUSBAND of


Anna Mclaughlin


(or) WIFE of.


(Husband's name in full)


12


AGE .... 7. 6Years.


.] .. ].Months .. ] ... 5 ... Dayz


If under 24 hours


.. Hours ......


Minutes


13 Usual


Occupation :


Retired


(Kind of work done during most working life)


14 Industry


or Business:


-


15 Social Security No ..


047-20-6920


16 BIRTHPLACE (City)


(State or country)


Champlainy.Y.


Was autopsy performed?


What test confirmed diagnosis ?


Clinical


NO


(Signed)


Ivan Iturralde


M. D.


(Address)


M.C.I.Bridgewater 9/14


6


19


PARENTS


18 BIRTHPLACE OF


FATHER (City).


Champlain,


(State or country)


N.Y.


19 MAIDEN NAME


OF MOTHER


Mary Senecal


20 BIRTHPLACE OF


MOTHER (City) ....


(State or country)


Champlain


N.Y.


6


Winthrop


Winthrop


Place of Burial or Cremation


(City or Town)


sept. 171,63


DATE OF BURIAL


7 NAME OF


FUNERAL DIRECTOR


Maurice w. kirby


ADDRESS


winthrop, dass.


Received and filed


SEP-24-1963


.. 19


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


Bridgewater


(City or Town making this return)


172


Registered No.


(Was deceased a


U. S. War Veteran,


Ww1


(if so specify WAR


Winthrop,


Mass.


(a) Residence. No ..


(Usual place of abode)


?


WIDOWED Married


DIVORCED


UNKNOWN


(Give maiden name of wife in full)


(a)


Cerebral ..... Hemorrhage


To Arteriosclerosis Disease (b)


yr$


Due To


(c)


Pulmonary .......... B.


yrs


OTHER


SIGNIFICANT


ChronicAlcoholism


yr$


No


17 NAME OF


FATHER


Augustus Roberts


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


50M - 10-61-931673


DEATH Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased CONDITIONS




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