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STATE DEPARZ OF PUBLIC HBALTH
~ ~ 0 ` ~~r ~i~mmana~r~di~ oaf i,~~uhu,~etts
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-r~ ~ JOMN_F. X. DAVOREN a
_,s- SECRETARY OF THE COMMONWEALTH
Norfolk s~~.t__._._______
- DIVISION Or VITAL lITATIETIq (~q « Town eakiaE 1?$ felon) ~
- } u COheaset 8TANDARD
1 (Ciq «Teos) CERTIFICATE OF DEATH ReEisterod No. -
COhasaet Kn 11 S (It sett ottatna i.. Iwspiw « i..ut.(io.,
Ne.._....-.._.._...... .Q.......~-.._._.___._...._..,._...._..--...._--•---_._-, $t. 1 ~K its xAI~EB Tatted of street asd oueebet)
• • • • ' ~ ~ I PRYBICIAN--IHPORTA
t
FCLI..NAIdE A21118 G~
Q~illis_.Y.._.._..__..._..__ v
Is,
M?d
~ ~ ~ I _
(lt deceased h s sarritd, widowed « diraced woos., Eire oho resides Dower)
ys? _ II opKitJ N?A~ .
~f a}} e R a N Scituate aaa
~ (a) Perwsest Residence. No....._iL9_I_.llk.....Y~-~.~.__._.Q~ St. D ~
(Ciq « teas asd Bute)
~ -
- ~ Ai6DICAL CERTIFICATE OF DSAT6 PERSONA AND STATISTICAL PARTICULARS
~ pATE OF 7 9 SEX 10 COLOR i1 SINGES (write tke ward)
DEATH -------•NQYamber____1.Q;..~l.~~i..-.... 1dARRIED Harried
` aie¦w (Dar) (Yea) Female White ~ n
VmoRCF~.D
r R E B Y C E7t T~~Y , tLat { at deceased - fr -UNKNOWN
lb~~~.._...-..._.._...., 19_ ttpp -..I.l~+~ 19__._ li It married. widowtd, «dirotted
•ractice: 1 iq us l~.r sties a _ ~3i.. 19-1..;~deat? is said to HUSBAND d ~na~d~p~s,~~__-.•-_.
ha~•e Rare . t_a.e secured a tke due stated abo+re, at -~-:~5__..N.e. INTEftrllf. ~alteI't~tJ 1i1L11~e io tWl)
EETIEEfiR \YIFE d ..._..___....-.______..l..._~__
~ • DEATH WAS CAUSED BY: IYMEDIATS CAUSE _ AEI ~E (Hoybaad's acme ie t¦Y)
though lal,~ 'o OEAig q It ostler it kwon
r Whose u/ Metastatic Cancer 13 AGE..34Ytaa...._l_1(oatls?~ Days ~ _._..Hoors._Sfiaols
t (~w To 1• Usual
,ems i^r:=•~ ,f ~ _ • .a Cancer of Colon 1 yr ottnpuioa ____Housewife _
• actu.r:. • (Kind d work dooe
im d i, • a ~M
ti Uur To doriaE east d workisE li(e)
ea ai~.~,, a~:.,• ~ tr, /~-3~ Is t.dastr, At Home.
« Bnsioess -
~ic~iFlcANr O -10 0 B
! CU.\DITIOIJS 16 Social Secaritt Na
- , 17 BIRTHPLACE (City) _ _
r~ t\u auopat perfaeed. (Sate « covatry) Ma$ a e
spftiff test eanfrsed diaseosis? ___..~.3-..9..tOlOtrrrvv
iuct~on t t+ e~ i --e~------._..__._....._._ Ito NAk1E OF
ensaire ~ FATHER Thomas F• DLif11
,hest w ar~aw? I f tt'as disease « iajuq is asr oat related to occupation d deceased? -.No--._ 19 AIRTIIPLACE OF D }
;f etticr a .+K! ~ H se. I.. FATHER (Girt)..-.......L~Q.ug~Qll~..._.. ~
~ specrtt • (State «couatp)
Frac:cr.._ jrlt~ z I
saw -
'a~atore) ~ i0 UTAIDEIC NAVE
- ~lI.D. aC OF k10THER Anna Shea
~:n Robert A Seidel
umstar.a~ ~ - < 21 BIRTHPLACE OF
~ (Pr' t o tra Naed ~ k(OTHsR (C.ttt)------BQa~~.CnP___.__.it_____-_...-,_..-_...r..
~ur.a c~ra= • sAddress)u[~QQ-n~~u~.~,f.sg.-~.jte .......-~1._lO/9~1_ 4 (Sett «cooattt) lua$sR
~ I HEREBY CERTIFY tLat a satisfactory sundard «rtifnte d deatk was fled
- r St..-- J03.A.~..-$-•---C_9mA.tiG1'~i.---.F.~O,~te-511_.._- ~A a,t BEFORE tke iwrial « tramit yereit was iswea:
Pace of Serial a Cremation (Girt «To¦a) Samuel A? BO$_CO
1~\TE OF BURIAL 19..1._± (SiEsstore d /1Eest Board et Healtk « j
~ ~\tfE OF A ent November 1 1
il'XERAL DIRECTOR $!J«
Gaffed do Sons _ -g-- 9? j
i - (OI&ial Dcsiasatios) (Date d Isssoe d Persil)
\DDRF-SS Country- Ways----N.~.~-~lfir_LiAt. 77 l
-
Reuir fled Novelllb...9~! 19J.~ '
t I.,.~,~t D[r. Walter J. Gillis e~ - ~ ~
. -(R
1, the undersigned,- hereby certify that 1 am the Registror of Vitol Records and Statistics; -
that as such I have custody of the records of births, marriages and deaths required by law to Ge kept
in my o,~ice; and I do hereby certify that the above is a true copy from said records.
WITNESS my hand and the GREAT SEAL OF THE COMMONWEALTH at Boston on
this 24T.N day of 19
SEPTEi~BER 9
HERBERT E. KISSER, JR.
Registrar of Vital Rt,cords and Statistics
- _ ~ _ ~ - _
X979 SAP 28- AM il= 3Q _
FIlEO ANG FECi)HUiU YEAR /
ST IUCIE COONTY. FLA.
l~OGER P017RAS ~j ?
CLERK CIRCUIT CO~~~.~!_. v
VOL.
RECORD YERIFIFQ._~'__ ~O~
PAGE
N° 366115 _ _ No~
' FEE :2.00 t~ _ roast R.N soM !-7a