USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 45
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I HEREBY CERTIFY that a satisfactory standard certificate of death wandled with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)"
B18489 10-25-63
(Date of Issue of Permit)
T. V.B. V
A TRUE COPY ATTEST:
23
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY 10/20 19 63 ... to.
That I attended deceased
10/23
19
from
63
I last saw hunglive on
10123, 1963 heath is said to
have occurred on the date stated above, at
00.30 AM
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH
A (a) CARDIAC ARREST
Due To
(b)
? MASSIVE PULM. EMBOLISM3minutes
Due To
? MYOC. INFARCT
(c)
OTHER
SIGNIFICANT
CONDITIONS
St. post hip arthroplasty 4 day
Was autopsy performed ?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
.....
(Signature)
M. D.
(Print or Type Name) RAPHAEL ADÄR
19
WINTHROP CEINETERY WINTHROP. 6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL Oct. 25
19.
7 NAME OF FUNERAL DIRECTOR
MAURIS+ MAURis
ADDRESS .......
man 48 So. Common St. LYan
Received and filed
OCT 2 9 1963 19.
William)
(Registrar) || (Official Designation)
1
Registered No.
10819
2 FULL NAME
155
PLEASANT
S
WINTHROP, MASS.
(('ity or town and State)
3 DATE OF
DEATH
10
8
(Address) ..... 330 BROOKLINE. QUE. 10/23
......
PARENTS
(Address)
A TRUE COPY ALITEST:
r
OF TON
CLERK
5
THRON
DEC - 41963 AM
X
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
Registered No.
229
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
Wilbur Herbert Freeman
(If deceased is a married, widowed or divorced woman, give also maiden name.)
125 Washington Avenue
St
(If nonresident, give city or town and State)
Length of stay: In place of death. 1 lyear ......... months ........ days. In place of residence + years.
... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
November
3
1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
, That I attended deceased from
DE0. 29, 1961, 10%.
Nov 3
I last saw himlive on
Nov.
2 16 death is said to
have occurred on the date stated above, at
93 Am
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
GLIOMA
INTERVAL BETWEEN ONSET AND DEATH 8 MO
Due To
(b)
Due To (c)
OTHER
HYPERTENSION & HYPER-
SIGNIFICANT
CONDITIONS
TENSIVE HEART DIS
3yrs
Was autopsy performed? YES OF HEAD
What test confirmed diagnosis ?
AUTOPSY.
5 Was disease or injury in any way related to occupation of deceased NO If so, specify
(Signature)
myronhiking
M. D.
MYRON N. KING MED
(Address)
222 PLEASANT 51 Date.
11/4/ 1963
Winthrop Cemetery
6
Winthrop, Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL November 5, 1963
7 NAME OF
FUNERAL DIRECTOR
alfred B. Marsle
ADDRESS
174 Winthrop St. Winthrop,
Received and filed
NOV 4 - 1963
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED married
WIDOWED
DIVORCED
UNKNOWN
male
white
11 If married, widewed, or divorced
Margaret Dawson
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE 69 Years 5
.Months ... 29. Days
If under 24 hours
Hours ......
Minutes
13 Usual
retired auditor
Occupation :
(Kind of work done during most working life)
14 Industry
or BusinessFirst .... Natural Bank
15 Social Security No ..
031-09-2401
Dorchester
16 BIRTHPLACE (City)
(State or country )
Massachusetts
17 NAME OF
FATHER
Edward Farster Freeman
PARENTS
18 BIRTHPLACE OF
FATHER (City)
Caledonia
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Flora Annie Wheelock.
20 BIRTHPLACE OF
MOTHER (City)
.Torbrook. ..
(State or country)
Nova Scotia
Mrs. Wilbur H. Freeman
19 ...
21 Informant
(Address)
125 Washington Ave. Winthrop
HEREBY CERTIFY that a satisfactory standard certificate of death T .: ass filed with me BEFORE the burial or transit permit was issued: Ralph E. Sirianni (+B)
(Signature of Agent of Board of Health or other)
Health Officer
Nav. of, 1963
(Registrar) || (Official Designation)
(Date of Issue of Permit)
TVR
A TRUE COPY ATTEST: RUE C
......
ORM R-301
for burial permit rd of Health s Agent. UCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH ot enter than one for each (b) and (c)
oes 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
62-932382
1
No ... 125 Washington Avenue
(Was deceased a
U. S. War Veteran,
if so specify WAR).
NO.
(a) Residence. No ..
(Usual place of abode)
19.
63
·,
(a)
(Print or Type Name)
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 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 bad been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
OF TOW
LERK
. Fr
6
5
NOV - 41963 PM
RM R-301
I
PLACE OF DEATH -
Suffolk (County)
winthrop. (City of Town)
No ... 76 Lowell Road
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD . OVIEILLE CERTIFICATE OF DEATH TATE
WINTHROP
(City or Town making this return)
Registered No. 230
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
NO.
(a)
Residence. No.
76 Lowell Road
(Usual place of abode)
Length of stay: In place of death3.6 .. years.
.. months. .. days. In place of residence3.6 .. years ......... months ... ... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
November
8
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
75
1953
to ......
oct
30
19
1.3
Nlast saw h. .. Alive on
6c+ 3:
19 ........ , death is said to
have occurred on the date stated above, at
7.00 AM m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
myocardial infarction
INTERVAL BETWEEN ONSET AND DEATH
(a)
(b) Arterio seleratic heart disease
2yrs
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS .
Failure - Savona
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
NÓ
(Signature)
H.B. Greenfield
M. D.
447 Shirley Printor Type Name)
(Address)
Winthree Mass Date ..
11-9
1963
Mass
Winthrop Cemetery Winthrop,
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Nov. 12,1963
19.
7 NAME OF
FUNERAL DIRECTOR
alfud B. March
ADDRESS 1.74 Winthrop St . Winthrop,
Received and filed
NOV 12 1963
19
( Registrar)
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the. word)
married
male
white
11 If married, widowed, or divorsed
Ethel Margaret Edwards
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
AGE
82Years.
2
Months
26
Days
If under 24 hours
Hours ......
.. Minutes
13 Usual
retired traffic manager
Occupation :
(Kind of work done during most working life)
14 Industry
or Business: wholesalewoolsales
15 Social Security No. 023-03-9002 Chelsea
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
Abbott Aidan Wilder
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Vermont
19 MAIDEN NAME
OF MOTHER
Margaret Alexander
20 BIRTHPLACE OF
MOTHER (City) ..
Chelsea
(State or country )
Massachusetts
M.
Mrs ..
John L. Wilder
21 Informant
(Address)
76 Lowell Road, Winthrop
Į HEREBY CERTIFY that a satisfactory standard certificate of death MasSssfiled with me BEFORE the burial or transit permit was issued: laeph 16 Seranne (3) (Signature of Agent of Board of Health or other) Heaith Officer Jetzt 16-1963
(Official Designation)
66
(Date of Issue of Permit)
TV. 13- V
· burial permit 1 of Health Agent. CTIONS R ERTIFICATE
R TYPE CAUSES ATH enter an one or each ) and (c)
not mean of dying, art failure, ;. It means or compli- ich caused
, if any, e rise to use (a), e under- use last.
ons contrib- ath but not he terminal lition given C.
932382
2 FULL NAME
John Merton wilder
(If deceased is a married, widowed or divorced woman, give also maiden name.)
St
(If nonresident, give city or town and State)
2yrs
Congestive her ..
NO
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 galls 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 wNOViin 21003cats 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.
M R-301
burial permit of Health gent. TIONS I RTIFICATE
TYPE CAUSES ATH enter in one r each and (c)
not mean of dying, ut failure, . It means or compli- ch caused
if any, e rise to se (a), e under- se last.
ns contrib- th but not se terminal ition given C.
PLACE OF DEATH
X SUFFOLK (County)
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)
231
Registered No.
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
JOHN MARMINNO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No
85 QUINCY AVE
WINTHROP
St
(City or town and State)
Length of stay : In place of death .......... years .......... months .......
days. In place of residence 50 years
months.
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
NOV.
10.
DEATH
1963
(Month)
(Day)
(fear)
4 I 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 4/115 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH
(a) Death presumably due
Due To
(b)
to natural causes,
Due Toprobably acute coronary (c)
OTHER
occlusion on basis of
History Winthrop Boardof Health
Was autopsy performed ?
What test confirmed diagnost
Charles Libermantin
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
Charles Liberman
M. D.
CHARLES
LIBERMAN
(Print or Type Name)
(Address)
WINTHROP, MAS Date 11/12/
. 19 63
6
WINTHROP
WINTHROP
I'lace of Burial or Cremation
(City or Town)
DATE OF BURIAL
NOV 13
1963
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP.
Received and filed
NOV 12 1963
19
( Registrar )|
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
WHITE
(write the word)
MALE
11 If married, widowed, or divorced
HUSBAND of
DOMENICA
PINO
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
I2
AGE 79 Years ..
Months ..
Days
If under 24 hours
.Hours ...
Minutes
13 Usual
WAITER
(RETIRED)
Occupation :.
(Kind of work done during most of iworking life)
14 Industry
or Business :.
RESTAURANT
15 Social Security No ....
010-09-3245-4
16 BIRTHPLACE (City) ..
(State or country )
ITALY
17 NAME OF
FATHER
STEFANO MARMINO
PARENTS
18 BIRTHPLACE OF
FATHER (City) ....
(State or country)
ITALY
19 MAIDEN NAME
OF MOTHER
CATERINA BATTAGLIA
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
ITALY
21 Informant
MIRS PAULINE FALCO
1.Adress) 123 QUINCY 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 , 6 Sirianni (B)
(Signature of Agent of Board of Health or other) , Health Officer
november12, 63
(Official Designation (Date of Issue of Permit)
T. V.B.V
A TRUE COPY ATTEST:
933404
I
WINTHROP (City or Town)
No. 85 QUINCY AVE
(Usual place of abode)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
NO
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
WIDOWED
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
TONY:
SERVICE NUMBER
..
ERK
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 fast illness from disease un- related to any form of injury. (2) Board of Health physicians will certifa to such deaths only as those of persons who, though disabled by recognize disease unterated 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.
X
M R-302
1
Hingham
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Hingham
(City or Town making this return)
Registered No.
232
f(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
Edward Patrick White
(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
(a) Residence. No.
(Usual place of abode)
72 Sargent
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death .. 2.
... years .......... months .......... days. In place of residencel.,2.years .......... months .......... days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
11 If married, widowed, or divorced
HUSBAND of
Susanna
Harrington White
(Give maiden name of wife in full)
(or) WIFE
(Husband's name in full)
12
4 hrs
AGE
8.6.ears.
-
Months ......
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Retired Dentist
Occupation :
(Kind of work done during most working life)
14 Industry
or Business:
Dentist
15 Social Security No.
-
16 BIRTHPLACE (City)
Cambridge
(State or country )
Mass.
17 NAME OF
FATHER
Edward P. White
18 BIRTHPLACE OF
London
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Catherine Dollard
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Currick on Sur
Ireland
6 St. Pauls
Arlington, Mass.
l'lace of Burial or Cremation
(City or Town)
DATE OF BURIAL
November 15, 1, 63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
Winthrop, Mass.
ADDRESS
Received and filed
NOV 1-8 1963
19
William Russell
681 Main Street
Hingham, Mass.
A TRUE COPY William X. Noward.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
November 14, 1963
/
/
THIS IS A PERMANENT RECORD
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
PLACE OF DEATH
Plymouth (County)
(City or Town)
1192 Main Street
No
2 FULL NAME
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
November 12, 1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
I.une .......
19
56
to.
Nov. 12
19
63
I last saw h.l .. lalive on
12, 19 6, Bleath is said to
have occurred on the date stated above, at
7:15 pm
INTERVAL
BETWEEN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
ONSET AND
DEATH
(a) Cerebral Vascular Accident
Due To
(b)
Hypertension
yrs.
(c)
Due To
Arteriosclerosis
yrs.
OTHER
SIGNIFICANTCoronary Heart Disease
CONDITIONS
3 yrs
Was autopsy performed?
No
What test confirmed diagnosis ?
clinical
5 Was disease or injury in any way related to occupation of deceased ? N.O.
If so, specify
(Signed)
Donald M.Garland
M. 1).
(Address)
Hingham, Mass .Date
11/12/63
PARENTS
21 Informant
(Address)
50M - 10-61.931673
(Registrar of City or Town where deceased resided)
Male
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
RECEIVED
GLER
WN
MASS
OF
MIN
THRI
OFFICE
WIN
INOM IN 1963 AM
X SUFFULIK (County) 1 WINTHROP (City or Town) 52 UPLAND PO.
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
233
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
PIC F. MARRUCHELLI
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 52 UPLAND RD
St.
WINTHROP
(Usual place of abode)
Length of stay: In place of death ..... years ....... .months. ........ days. In place of residence.
40 years.
.months ....
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
(write the word)
10 SINGLE
MARRIED
WIDOWED
or DIVORCED MARRIED
4 I HEREBY
CERTIFY
JAN 9
19
63
to
NOV
13
I last saw h.j Malive on death is said to
have occurred on the date stated above, at
935Pm.
INTERVAL
BETWEEN
ONSET AND
DEATH
3_MO
Due To METASTASIS TO BRAIN (b)
XCHEST
Due To (c)
OTHER
DIABETES MELLITUS
SIGNIFICANT
CONDITIONS
Was autopsy performed? No .
What test confirmed diagnosis ?
BIOPSY AT PRATT
Hos
5 Was disease or injury in any way related to occupation of deceased? If so, specify
NO
(Signed) Mysonb. King M. 1). MYRON NUKING M.T (PRINT OR TYPE SIGNATURE}
(Address) WUPLEASANT 51
WINNYED MAPS . Date. Nov 14 63
6 WINTHROP
WINTHROP (City or Town)
Place of Burial or Cremation DATE OF BURIAL MUL 14 1943
7 NAME OF
FUNERAL DIRECTOR
MAURICE W MIRBY
ADDRESS WINTHROP.
Received and filed
NOV 16 1963
19
(Registrar)
PARENTS
17 NAME OF
FATHER
RALFAELE HARRUCHELLi
18 BIRTHPLACE OF FATHER (City) (State or country) ITALY
19 MAIDEN NAME OF MOTHER VINCEMA DE SERNIA
20 BIRTHPLACE OF MOTHER (City) (State or country) ITALY
21 Informant (Address)
MARIA MARRUCHELLI
52 UPLAND RD WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Neph E Jerianne (3)
(Signature of Agent of Board of Health or other)
Health Officer
November 15, 1963
(Date of Issue of Permit)
T. V.B.V
-301A
TIONS
RTIFICATE
ing DEATH enter in one r each and (c)
not mean of dying, rt failure, It means or compli- h caused
if any, rise to se (a), , under- se last.
ns contrib- th but not e terminal tion given
apter 137. . requires o print or cause or death on cates, and Acts of es Physi- nt or type signature.
-925686
3 DATE OF
DEATH
Nov.
13
1963
(Year)
(Month)
(Day)
That I attended deceased
1963
10a If married, widowed, or divorced
HUSBAND of
MARIA N LALLÍ
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 76 Years.
Months.
Days
If under 24 hours
Hours ...
Minutes
13 Usual
Occupation :
CLOTHING DESIGNERS.
(Kind of work done during most of working life)
14 Industry
or Business :
MENS CLOTHING
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
ITALY
4 WILS
PLACE OF DEATH
No.
PHYSICIAN - IMPORTANT [(Was deceased a
U. S. War Veteran,
[if so specify WAR)
(If nonresident, give city or town and State)
NOV 13 1963
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
UNDIFFERENTIATED
CARCINOMA OF MAXILLA
(a)
# WAS
(Official Designation)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
OF TOW; ... 12 ..
ORGANIZATION AND OUTFIT
SERVICE NUMBER
IL.
NIN
1 RI
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 i .. clude 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.
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