Town of Winthrop : Record of Deaths 1963, Part 52

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 52


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).


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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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