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