USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 52
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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.
TO:
11.1%
6
THROP
DEC 2 61963 AM
M R-301
1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
No. 120 Circuit Road
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. 265
[(If death occurred in a hospital or institution, .St. Į give its NAME instead of street and number)
2 FULL NAME
Leo H. Overlan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(if so specify WAR)
(a)
Residence. No ...
170 Circuit Road
St
(If nonresident, give city or town and State)
(Usual place of abode)
Length of stay: In place of death2 .. years.
.... months ..
.days. In place of residence.Q .... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
December 26, 1963
DEATH
(Month)
(Day)
(Year)
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
ic: 25 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Death Presumably due to
INTERVAL . BETWEEN ONSET AND DEATH
Due To
natural causes probably
(b) acute coronary occlusion
Due To
on basis of history and
(c) examination.
OTHER
Winthrop Boardy Rulle
SIGNIFICANT
CONDITIONS
Chealles d'elleanden ne
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased 1/2) If so, specify
(Signature)
CHARLES
LIBERMAN
(Print or Type Name)
(Address)
WINTHROP
Dat 2/27/1963
6 Winthrop Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
December30
19.63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
Winthrop, Mass
ADDRESS
Received and filed
DEC 30 1963
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWEIWidowed
DIVORCED
UNKNOWN
11 If married, widowed, or divorced. Hanora Murphy
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
AGE.69 Years
Months.
Days
If under 24 hours
Hours ..... .. Minutes
13 Usual
Occupation :
Retired Book binder
(Kind of work done during most working life)
14 Industry
Book Binding
or Business:
15 Social Security No ...
033-34-9072
Boston
16 BIRTHPLACE (City)
(State or country )
Mass
17 NAME OF
FATHER
John Overlan
PARENTS
18 BIRTHPLACE OF
FATHER (City).
Syracuse.
M. D.
(State or country)
New York
19 MAIDEN NAME
OF MOTHERAlice O'Connor
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
2I Informant
Lillian .... Abbott,.
(Address)
31 Palmyra St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
Falah 6. Sirianni
(Signature of Agent of Board of Health or other)
Nereth Officer
12/30/63
(HB)
(Official Desiguanon) (Date of Issue of Permit)
T V. B.
burial permit of Health gent. 'IONS
TIFICATE
TYPE CAUSES TH nter n one each and (c)
not mean of dying, t failure, It means r compli- h caused
if any, rise to e (a), under- e last. s contrib- h but not e terminal ion given . .
32382
A TRUE COPY ATTEST:
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
WW # 1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
12-11-17
DATE OF DISCHARGE
7 .-. 25-19
RANK, RATING
MM 2cl
ORGANIZATION AND OUTFIT.
IJ .. S.Navy.
SERVICE NUMBER
174 38 36
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.
MIM
CLERK
5
DEC 3 01963 PM
M R-301
1
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.
266
45 NEPTUNE AVE. No
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
45
NEPTUNE AUE.
St
WINTHROP
(City or town and State)
Length of stay: In place of death. 20 years monthsdays. In place of residence 0 years. ... months ... ... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DECEMBER
26
1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from 19. 19 to ....
I last saw h ...... alive on 19 .. ..... , death is said to
have occurred on the date stated above, at
8:00 P.m.
INTERVAL BETWEEN ONSET AND DEATH
1)ue
to natural causes
Due
(c)
probably acute coronary
OTHEReclusion on basis of history SIGNIFICANT winthrop Board of Health
CONDITIONS
Charles Liberman, Mint
Was autopsy performed
What test confirmed diagnosis ?
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
MARRIED
11 If married, widowed, or divorced
HUSBAND of
FRANCES
GOLDMAN
(or) WIFE of
(Husband's name in full)
12
59
Months ....
.Days
If under 24 hours
Hours ... . . Minutes
13 Usual
Occupation :
EXECUTIVE
(Kind of work done during most of iworking life)
14 Industry
or Business :
TOWN PAINT & SUPPLY
15 Social Security No ..
TO BE FILED LATER
16 BIRTHPLACE (City). .
(State or country)
EAST BOSTON, MASS.
17 NAME OF
FATHER
LOUIS SANDLER
PARENTS
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
RUSSIA
19 MAIDEN NAME
OF MOTHER
BELLA FREEDMAN
20 BIRTHPLACE OF MOTHER (City). (State or country) POLAND
21 Informant
MRS- FRANCES SANDLER
(Address)
45 NEPTUNE AVE, WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Falah E Sirianne (Signature of Agent of Board of Health or other)
Health Officer
Dec. 28. 1963
(Official Designation) (Date of Issue of Permit)
(Registrar)
A TRUE COPY ATTEST:
5 Was disease or injury in any way related to occupation of deceased? N/B. If so, specify ....
(Signature)
Olesales
Liberman
M. D.
CHARLES
LIBERMAN
(Print or Type Name) WINTHROP, MASS, Date 12/27/1963
(Address)
BNAI BRITH OF SOMERVILLE - PEABODY 6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
DECEMBER 29 1) 63
7 NAME OF
FUNERAL DIRECTOR
BENJAMIN BIRNBACH
ADDRESS
1668
BEACON ST. BROOKLINE
Received and filed
BEC.3.0.1963
19
933404
burial permit of Health Agent. TIONS R RTIFICATE
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 ke terminal lition given
(City or Town making this return)
MAURICE MORRIS SANDLER
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
No
(Give maiden name of wife in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Death presumably due
(a) ....
- (b)
(Usual place of abode)
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 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.
OF
1.1 1.2.
OFFICE
MI:
JLERK
00
THROP
DEC 3 01963 PM :
I 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
Registered No.
267
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Joseph Reilly
(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 ...
39 Irwin St, Winthrop
(Usual place of abode)
S
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months.'
5
.. days. In place of residence. 20
.. months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCED Married
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
Elizabeth Rolle( Henderane )
(Give maiden name of wife in full)
(Husband's name in full)
INTERVAL
BETWEEN
(or) WIFE of.
12
58
ONSET AND
DEATH
9 HRS
Years
10
.. Days
If under 24 hours
Hours ... ...
Minutes
13 Usual
Burger
Occupation :
(Kind of work done -during most working life)
14 Industry
or Business :
Defit Store
15 Social Security No.
16 BIRTHPLACE (City)
(State or country )
Mary
17 NAME OF
FATHER
James Reilly
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Ireland
Richard & Really
21 Informant
(Address)
1 Vieta Drove Danvers Mars
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Palpi Virianna
(Signature of Agent of Board of Health or other) (NB)
Thearte Offices
12/30/63
(Date of Issue of Permit)
A TRUE COPY ATTEST:
32382
M R-301
burial permit of Health Agent. TIONS
RTIFICATE
TYPE CAUSES ATH enter in one r each and (e)
not mean of dying, rt failure, . It means of compli- ch caused
if any, e rise to se (a), e under- se last.
ns contrib- th but not e terminal ition given
5 Was disease or injury in any way related to occupation of deceased ?No If so, specify
(Signature)
mysou n. King
M. D.
MYDIN N. KING M.D
(Print of Type Name)
(Address)
222 PLEASANT S
.. Date .....
12/270 63
Wanthrof Mars
6
Place of Burial of Cremation
(City or Towin)
DATE OF BURIAL
Dec 30
63
19.
7 NAME OF
FUNERAL DIRECTOR
ErnestMaggiano
ADDRESS
147 Wanting St Minthaof
Received and filed
DEC 2: 1963
19
4 MOS
Due To (c)
CHRONIC BRONCHITIS 5
OTHER
SIGNIFICANT
CONDITIONS
EMPHYSEMA -
12YRS
Was autopsy performed?
No
What test confirmed diagnosis ?
CLINICAL
EMBOLUS
Due To ADENO CARCINOMA CF
(b)
SIGMOID COLON
(a)
ACUTE PULMONARY
Dece, ber
27,
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
to ....
JAN
19
That I attended deceased from
57
DEC- 27
1963
I last saw himalive on
DEC 22
1965
death is said to
have occurred on the date stated above, at
300rg
.. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
3 DATE OF
DEATH
No ........
winthrop Community Hospital
Winthrop
(City or Town making this return)
( Registrar) (Official Designation)
Goalin
PARENTS
WINNIFRED
Winthrop
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RECE VED
6 5
NTHROR
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.
DEC 301963 PM
-301A 1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
268
[(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)
2 FULL NAME Hilmer J . Hanson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
35Moore St.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death ...... . .. years ..... 3 . months. ..
days. In place of residence ... ].Q .. years. months. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIEDM
WIDOWEMarried
or DIVORCED
4 I HEREBY CERTIFY,
MARCH 20
1954.
to DECO 29,
1963
I last saw h.j.inalive on
DEC.
27.
19. 2.3, death is said to
have occurred on the date stated above, at 1:2+2=p.m.
INTERVAL
BETWEEN
ONSET AND
DEATH
6MOS.
10a If married, widowed, of M. HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.
94Years
8
Months.
12.
.Days
If under 24 hours
Hours ...........
.Minutes
13 Usual
Occupation :
Machinist Retired
(Kind of work done during most of working life)
14 Industry
or Business :
Clifford Manufacturing
15 Social Security No.
025-09-9784
16 BIRTHPLACE (City) (State or country)
Sweden
17 NAME OF
FATHER
Hanson
18 BIRTHPLACE OF FATHER (City) (State or country)
Sweden
19 MAIDEN NAME OF MOTHER unknown
20 BIRTHPLACE OF MOTHER (City) (State or country) Sweden
21
Mrs.
Evelyn Kratman
Informant (Address)
35 Moore St. Winthrop, Mass
1 HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph 6. Sirianni (Signature of Agent of Board of Health or other) (HB)
Health Officer
12/30/63
(Official Designation)
(Date of Issue of Permit)
T
IONS
TIFICATE
ng DEATH nter one each and (c)
not mean f dying, t failure, It means r compli- caused
if any, rise to e (a), under- e last.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
ARTERIOSCLEROSIS
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. M. I PHONSTEIN UP. M.D.
(PRINT OR TYPE SIGNATURE)
(Address) 73 BART
6 Glenwood Cemetery
Everett
Place of Burial or Cremation DATE OF BURIAL
(City or Town) Dec. 31, 1963
7 NAME OF FUNERAL DIRECTOR J.E.Henderson Co.
ADDRESS 517 Broadway Everett
Received and fled
DEC 30 1963
19
(Registrar)
PARENTS
3 DATE OF
DEATH
PEC. .24 1963 (Year)
(Month) (Day) /
That I attended deceased from
Johannson
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) CARCINOMAOF URINARY
BLADDER.
Due To (b)
GENERALIZED
s contrib- but not terminal ion given
pter 137, requires print or ause or leath on ates, and Acts of s Physi- t or type ignature.
925686
T
No. Bay View Nursing Home
(a) Residence. No. (Usual place of abode)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
RECEIVED
SERVICE NUMBER
OF TOWA
1.1
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.
10
OFFICE
MINI
W
THROP
DEC 3 01963 ...
M R-301
I
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.
269
2 FULL NAME
(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)
Length of stay : In place of death .......... years .......... months ..
1
days. In place of residence.
35 ears
........ months ...
„days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
December
31
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
708-2
5%
ACC31
I last saw
h ...... alive on
have occurred on the date stated above, at 2ª2 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Carrara Thrombosis
(a)
arteriosclerosis
years
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Bronchopnummer
24 hrs.
Was autopsy performed ?
20
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of decease If so, specify
CERANDE (Signature) G. Guy M. D. sofarating Pr. cad Sammans 1/3, 63
6 Holy Cross alden
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL January 2, 19 64
7 NAME OF
FUNERAL DIRECTOR ichard C. Kirby Inc.
ADDRESS 217 Bennington St., F. BOS.
Received and filed
JAN 3 1964
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
W
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
11 If married, widowed, or divorced
HUSBAND of
Amalia Pelosi
(or) WIFE of
(Husband's name in full)
AGE
Years.
.Months
25 Days
If under 24 hours
Hours ......
.Minutes
13 Usual
Occupation :
henairman
(Kind of work done during most working life)
14 Industry
or Business :.
Shoe Lachinery
15 Social Security No.
011-10-6326
16 BIRTHPLACE (City)
(State or country)
Italy.
17 NAME OF
FATHER
Joseph aiellano
PARENTS
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
Caroline Famiglitti
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
21 Informant
( Address)
Alphonso Kiellaro - son
Marblehead, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: (alph 6 Sirvanne (S) (Signature of Agent of Board of Health or other) Health Officer January 2,19 6
(Registrar ) (Official Designation)
(Date of Issue of Permit)
TVPV
burial permit of Health Agent. TIONS
RTIFICATE
TYPE CAUSES ATH enter an one r cach and (c)
not mean of dying, ut failure, . It means or compli- ch caused
, if any, e rise to ase (a), e under- se last.
ns contrib- th but not he terminal ition given
932382
A TRUE COPY ATTEST:
PHYSICIAN - IMPORTANT
Frank S. Maiellano
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